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Is rate more important than rhythm in treating atrial fibrillation? Yes

BMJ 2009; 339 doi: (Published 21 August 2009) Cite this as: BMJ 2009;339:b3173
  1. Timothy R Betts, consultant cardiologist and electrophysiologist
  1. 1Department of Cardiology, John Radcliffe Hospital, Oxford OX3 9DU
  1. EP.doctors{at}

    Timothy Betts argues that focusing on rate will cause less harm to patients, but Andrew Mitchell (doi:10.1136/bmj.b3174) believes that achieving sinus rhythm will have better long term results

    Both sides of the debate on whether to control rhythm or rate agree that sinus rhythm is better than atrial fibrillation.1 If a strategy to control rhythm could guarantee to be efficacious, cost effective, and have no risk of adverse events, there would be no argument. Unfortunately, this is rarely the case. Rhythm control is difficult to achieve and initially requires the use of potentially toxic drugs. If the objective is to “first do no harm,” rate control is more important.


    Six randomised controlled trials comparing rate and rhythm control have clearly shown that mortality (whether as a primary or composite end point) is not reduced with rhythm control.2 3 4 5 6 7 In the two largest of these there was even a trend to increased mortality in the rhythm control group.3 4 This is probably because of the potential toxicity of rhythm control drugs and the inappropriate withdrawal of warfarin …

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