Restore normal heart rhythm or control heart rate?

Photo of an older couple cycling (PantherMedia / Andriy Popov)

People with atrial fibrillation have two main treatment options: Treatment to restore their heart rhythm or treatment to control their heart rate. Studies have shown that there are no differences between these treatment approaches in terms of life expectancy and the risk of developing medical conditions associated with atrial fibrillation.

Treatment for atrial fibrillation can either aim to restore a normal heart rhythm or control the heart rate. The heart rate is the number of heartbeats per minute (pulse). The heart rhythm is the pattern of electrical impulses that make the heart muscle squeeze and pump. These electrical impulses can be seen as electrical activity in an ECG (electrocardiogram). The two treatment approaches are:

  • Treatment to control the heart rate: The aim of this approach is to change the pulse to a normal level. If someone has a high pulse, the usual treatment target is a resting pulse of under 110 beats per minute. This sometimes isn’t enough to relieve the symptoms. Doctors may then try to reduce the resting pulse even further. Heart rate control treatment doesn't aim to restore a normal heart rhythm.
  • Treatment to restore a normal heart rhythm: The aim of this kind of treatment is to restore a normal heart rhythm (sinus rhythm). This can be done using medication or weak electric shocks (pharmacological or electrical cardioversion). Afterwards, people usually take medication known as anti-arrhythmics to try to prevent their heartbeat from becoming irregular again. If cardioversion isn’t successful, or if the medication is poorly tolerated, doctors can try to restore the normal heart rhythm through a heart procedure known as catheter ablation. If the normal heart rhythm is successfully restored, the heart rate may return to normal too. But a lot of people still need to continue taking a low dose of beta blockers in order to reduce their heart rate.

The choice of treatment will depend on various factors, including the person’s age, general health, other medical conditions they may have, and how severe their symptoms are.

Comparing the two treatment approaches

A group of researchers from the University of Lisbon analyzed studies that compared treatment to restore a normal heart rhythm with treatment to control the heart rate. They summarized the results of eight randomized controlled trials (high-quality studies) involving a total of 7,500 participants. The participants were 68 years old on average. Some of them had had atrial fibrillation for longer than others. Many of them had further risk factors for a stroke.

The researchers analyzed data on the following treatment-related aspects:

  • Life expectancy
  • Sudden cardiac death
  • Stroke caused by a blood clot
  • Blocked blood vessels in parts of the body other than the brain
  • Bleeding caused by anticoagulants (anti-clotting medication)

Overall, the analysis of research results showed that there were no differences between the two treatment approaches regarding any of these aspects.

Unanswered questions

The research couldn’t provide answers to all of the questions that are important to people with atrial fibrillation. For instance, it didn’t look into whether the two different treatment approaches had different effects on the development or progression of heart failure (cardiac insufficiency). Also, none of the studies looked at catheter ablation to restore the normal heart rhythm.