Restoring a normal heart rhythm: the pros and cons

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In , the rhythm of the heart is irregular and the heart usually beats faster than normal. The high pulse can be reduced with medication if necessary. There are also treatments that aim to restore and maintain a normal heart rhythm. These are suitable for people who have severe symptoms, for instance.

There are two different approaches to treating the symptoms of :

  • Reducing the heart rate (heart rate control)
  • Resetting the rhythm of the heart (cardioversion)

Heart rate control treatments aim to reduce the high pulse using medication. They do not try to restore a normal heart rhythm (sinus rhythm). Heart rate control treatment is sometimes enough to manage the symptoms.

The aim of cardioversion is to restore the normal ("sinus") heart rhythm. But a restored heart rhythm may become irregular again afterwards. The risk of this happening can be reduced with medication or a certain procedure.

Each of these treatment approaches has its pros and cons. So it's worth carefully considering them together with your doctor. The most suitable treatment approach to start with will depend on various factors. These include the severity of the symptoms, whether the person has other medical problems too, their age, whether they have had before, and for how long. Their personal preferences will play a role too.

What is heart rate control treatment?

This treatment approach reduces the high pulse using medication. The aim is to reduce the heart’s workload and relieve symptoms such as palpitations (a pounding and racing heart). The resting heart rate is reduced to less than 110 beats per minute at first. This is typically done using beta blockers. If that isn’t enough to relieve the symptoms, doctors can try to lower the heart rate further, either by using a higher dose of the same medication or using additional medications. The aim of treatment isn't to reset the heart rhythm at first.

Reducing the pulse can already be enough to relieve the symptoms. If you still have symptoms despite a reduction in pulse, it can be a good idea to try to reset the rhythm of your heart.

What is cardioversion?

The aim of this treatment is to try to restore the normal rhythm of the heart (the “sinus” rhythm), either with medication or by delivering controlled electric shocks to the heart. After cardioversion, people sometimes take medication to stabilize their heart rate (anti-arrhythmics) and ultimately prevent from recurring. A procedure known as ablation may be considered too in certain situations, with the aim of further stabilizing the heartbeat.

But it isn’t always possible to prevent from returning. In about 50 to 70 out of 100 people, this irregular heart rate returns within three years despite having stabilizing treatment.

Choosing a treatment strategy

If treatment to reduce the pulse relieves the symptoms enough, that can be the treatment of first choice. Research has shown that treatment to reset the heart rhythm doesn't have any advantages in that case: It doesn't increase life expectancy or offer better protection from strokes.

It is important to know that neither of the two treatment approaches can completely prevent . If this irregular heart rate comes back, blood clots can form. Because of this, most people have to take anticoagulant medication as well (to prevent strokes), regardless of which of the two treatment approaches they choose.

There are two main reasons for only having treatment to reduce the heart rate:

  • There are fewer check-up appointments because you take fewer medications.
  • The risk of side effects is lower.

Resetting the heart rhythm (cardioversion) can relieve the symptoms a little better. So it's a treatment option for people who still have bothersome symptoms despite having had treatment to reduce their pulse. But cardioversion is more likely to cause side effects.

For this reason, many medical societies only recommend cardioversion if other treatments aren’t effective enough.

The decision about whether or not to have cardioversion treatment isn't a final decision: Your situation may change over time, leading to a change in treatment strategy.

Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50(5): e1-e88.

Packer DL, Mark DB, Robb RA, Monahan KH, Bahnson TD, Poole JE et al. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA 2019; 321(13): 1261-1274.

Sethi NJ, Feinberg J, Nielsen EE, Safi S, Gluud C, Jakobsen JC. The effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter: A systematic review with meta-analysis and Trial Sequential Analysis. PLoS One 2017; 12(10): e0186856.

Valembois L, Audureau E, Takeda A, Jarzebowski W, Belmin J, Lafuente-Lafuente C. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev 2019; (9): CD005049.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Updated on January 6, 2021
Next planned update: 2024


Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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