Recent innovations have the potential to improve rhythm control therapy in patients with atrial fibrillation (AF). Controlled trials provide new evidence on the effectiveness and safety of rhythm control therapy, particularly in patients with AF and heart failure. This review summarizes evidence supporting the use of rhythm control therapy in patients with AF for different outcomes, discusses implications for indications, and highlights remaining clinical gaps in evidence. Rhythm control therapy improves symptoms and quality of life in patients with symptomatic AF and can be safely delivered in elderly patients with comorbidities (mean age 70 years, 3-7% complications at 1 year). Atrial fibrillation ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy, but recurrent AF remains common, highlighting the need for better patient selection (precision medicine). Antiarrhythmic drugs remain effective after AF ablation, underpinning the synergistic mechanisms of action of AF ablation and antiarrhythmic drugs. Atrial fibrillation ablation appears to improve left ventricular function in a subset of patients with AF and heart failure. Data on the prognostic effect of rhythm control therapy are heterogeneous without a clear signal for either benefit or harm. Rhythm control therapy has acceptable safety and improves quality of life in patients with symptomatic AF, including in elderly populations with stroke risk factors. There is a clinical need to better stratify patients for rhythm control therapy. Further studies are needed to determine whether rhythm control therapy, and particularly AF ablation, improves left ventricular function and reduces AF-related complications.

AFNET Münster Germany

Department of Cardiology 2 Electrophysiology University Hospital Münster Münster Germany

Department of Cardiology Asklepios Kliniken St Georg Hamburg Germany

Department of Cardiology Electrophysiology University Heart Center University Hospital Hamburg Eppendorf Hamburg Germany

Department of Clinical Research University of Southern Denmark and Odense University Hospital Odense Denmark

Department of Medical Biometry and Epidemiology University Medical Center Hamburg Eppendorf Hamburg Germany

Department of Neurology University Hospital Würzburg Würzburg Germany

DZHK partner site Hamburg Kiel Lübeck Hamburg Germany

Garibaldi Nesima Hospital Catania Italy

Hospital Clinic Barcelona Barcelona Spain

Institute for Clinical and Experimental Medicine Prague Czech Republic

Institute of Cardiovascular Sciences University of Birmingham and University Hospitals Birmingham NHS Foundation Trust IBR 136 Wolfson Drive Birmingham UK

Isala Diagram B 5 SMO Zwolle Zwolle Netherlands

Medical University Department Kantonsspital Aarau Aarau Switzerland

National Institute for Health Research Leicester Biomedical Research Centre University of Leicester Glenfield General Hospital Leicester UK

National Institute of Cardiology Warsaw Poland

Sandwell and West Birmingham NHS Trust Birmingham UK

Semmelweis University Budapest Hungary

St Vincenz Hospital Paderborn Cardiology and Intensive Care Medicine Paderborn Germany

Unit of Electrophysiology and Cardiac Pacing Ospedale Dell'Angelo Venice Italy

Universitätsspital Zürich Zürich Switzerland

University Hospital Antwerp Antwerp Belgium

University of Groningen University Medical Center Groningen Groningen Netherlands

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Anticoagulation, therapy of concomitant conditions, and early rhythm control therapy: a detailed analysis of treatment patterns in the EAST - AFNET 4 trial