Rhythm or rate control in atrial fibrillation - Pharmacological intervention in atrial fibrillation (PIAF): a randomised trial

Background Atrial fibrillation is the most commonly encountered sustained c ardiac arrhythmia. Restoration and maintenance of sinus rhythm is believed by many physicians to be superior to rate control only. However, there are no prospective data that compare both therapeutic strategies. Methods The Pharmacological Intervention in Atrial Fibrillation (PIAF) tria l was a randomised trial in 252 patients with atrial fibrillation of betwee n 7 days and 360 days duration, which compared rate (group A, 125 patients) with rhythm control (group B, 127 patients). In group A, diltiazem was use d as first-line therapy and amiodarone was used in group B. The primary stu dy endpoint was improvement in symptoms related to atrial fibrillation. Findings Over the entire observation period of 1 year, a similar proportion of patients reported improvement in symptoms in both groups (76 responders at 12 months in group A vs 70 responders in group B, p=0.317). Amiodarone administration resulted in pharmacological restoration of sinus rhythm in 2 3% of patients. Walking distance in a 6 min walk test was better in group B compared with group A, but assessment of quality of life showed no differe nces between groups. The incidence of hospital admission was higher in grou p B (87 [69%] out of 127 vs 30 [24%] out of 125 in group A, p=0.001). Adver se drug effects more frequently led to a change in therapy in group 3 (31 [ 25%] patients compared with 17 [14%] in group A, p=0.036). Interpretation With respect to symptomatic improvement in patients with atr ial fibrillation, the therapeutic strategies of rate versus rhythm control yielded similar clinical results overall. However, exercise tolerance is be tter with rhythm control, although hospital admission is more frequent. The se data may serve as a basis to select therapy in individual patients.