In patients with persistent atrial fibrillation, is there any benefit to pursuing sinus rhythm?
My initial answer was yes, both because we've had some recent literature reporting the benefits of sinus rhythm, and because it makes intuitive sense to me that being in sinus rhythm, as compared to being in paroxysmal or persistent afib, would decrease the risk of stroke. However, I did not know what the medical literature says.
First, I read this article which reviews the factors associated with an increased likelihood of sinus rhythm after cardioversion: AF duration < 6 months, age < 65 yo, body weight < 80 kg, non-smoker (if female), certain AA meds (including amiodarone, sotalol, flecainide, and propafenone), and maybe meds that block the RAA system. There is also evidence that repeating a cardioversion for early (first three months) recurrence of AF is more likely to lead to maintenance of sinus rhythm long term.
I then reviewed some of the landmark studies comparing rate and rhythm control in afib:
AFFIRM (no difference in mortality, increased risk of hospitalization with AAs)
RACE (no difference in QOL)
STAF (no difference in 1* endpoint which was composite of mortality/CPR/embolic event, decreased risk of hospitalization with rhythm control)
Of course, all of these good RCTs used intention to treat analyses, and varying proportions of the patients in the rhythm control group had recurrent afib. The article I'm attaching here is one that looked at the patients in AFFIRM through the lens of their rhythm, and they found that being in sinus rhythm and using warfarin were both associated with an improved prognosis. Of course, the authors point out that we don't know if it is the sinus rhythm itself that is the explanation, or if sinus rhythm is a marker for some unknown factor. I will also direct you to this study which found that maintaining sinus rhythm after CV with the use of dofetilide leads to decreased mortality and decreased hospitalizations.
So, I stand by my assessment that there is prognostic value in being in sinus rhythm - but given the duration of this particular patient's afib, I am less convinced about the likelihood of success now and so am changing my plan to defer a CV and follow (although I've reached out to an EP colleague for a second opinion because I don't know that the answer is no).
I've also requested this article from InterLibrary Loan and will share it if/when I get it - it looks like a perspective/review piece on how to think about rate v rhythm control today, in 2025. Would appreciate any thoughts from any of you, too!
Ecker V, Knoery C, Rushworth G, et al. A review of factors associated with maintenance of sinus rhythm after elective electrical cardioversion for atrial fibrillation. Clinical Cardiology. 2018;41(6):862-870. doi:https://doi.org/10.1002/clc.22931
Pedersen OD, Bagger H, Keller N, Marchant B, Køber L, Torp-Pedersen C. Efficacy of Dofetilide in the Treatment of Atrial Fibrillation-Flutter in Patients With Reduced Left Ventricular Function. Circulation. 2001;104(3):292-296. doi:https://doi.org/10.1161/01.cir.104.3.292
Roman S, Patel K, Hana D, et al. Rate Versus Rhythm Control for Atrial Fibrillation: From Affirm to EAST-AFNET 4 – a Paradigm Shift. Future Cardiology. 2022;18(4):354-353. doi:https://doi.org/10.2217/fca-2021-0034
