In many patients with atrial fibrillation (AF) and with few symptoms, the management of the disorder can be limited to the control of the heart rate without trying to restore sinus rhythm. Traditionally, the objective, in these cases, is to obtain a heartbeat similar to the one in such a subject but as to sinus rhythm, even if in a retrospective analysis on two trials on the comparison between rhythm and heart rate has not shown any significant clinical advantages with the strict control of heart rate. Now, a Dutch trial has randomized 614 patients with atrial fibrillation, eligible for the control of heart rate alone through intensive management (< 80 bpm at rest and < 110 bpm under little strain) or a less strict control (< 110 bpm at rest). At the end of the starting phase, during which the highest pharmacological dose has been gradually reached, the average resting heart rate was clearly different in the two groups (76 vs. 93 bpm), but after one year the two averages got nearer (75 vs. 86 bpm). After 3 years, the endpoint made up of deaths, hospitalizations for heart failure, stroke, embolisms, bleedings and severe arrhythmias, was not significantly different in the two groups.
This is the third trial showing the poor usefulness of a strict control of heart rate during atrial fibrillation. But what should be noted is that the follow-up of these three trials has been relatively short, and we cannot know whether heart remodeling can be negatively influenced by the high heart rate during the years. In the end, considering the negative effects of the drugs and of the obtainable clinical results, we must always keep in mind that the aim is to treat a patient and not his/her electrocardiogram.
