Discussion
In the largest prospective AF dataset from the Balkans, rate control is
more frequently chosen strategy for symptom management (64.3%) than
rhythm control (35.7%). Our principal findings were as follows:i) patients assigned to rhythm control strategy were younger,
with less concomitant diseases and lower stroke and bleeding risk, but
more likely to have symptoms attributable to AF, inadequately controlled
HR and paroxysmal AF than patients with rate control, ii) EHRA
symptom score is not significantly associated with rhythm control
strategy, iii) among rhythm control drugs, amiodarone was the
most often used one, whereas beta-blockers were most commonly used
agents for rate control strategy, i v) the use of rhythm control
strategy in patients with paroxysmal AF has been significantly
associated with the presence of AF-related symptoms, and v)non-pharmacological therapies were less often used compared with ECV.
The Balkan region has generally been under-represented in prior
registries or trials. In the EURObservational Research Programme Atrial
Fibrillation Pilot Registry (EORP-AF Pilot) [25], rate control was
also more often used than rhythm control. The general trend with younger
patients with less comorbidities who were chosen for rhythm control
strategy is present also in EORP-AF Pilot Registry, Outcomes Registry
for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry
and Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial
Fibrillation (RECORDAF) [25-27]. In our analysis, women received
more commonly rate control what was consistent with other dataset
[28]. Patients with more prevalent concomitant diseases might have
been assigned to rate control strategy because of contraindications to
anti-arrhythmic drugs for rhythm control. Younger patients with less
comorbidities appear to be more active and may complain of higher burden
of symptoms during daily activities.
Patients with more prevalent symptoms attributable to AF managed with
rhythm control strategy were also seen in other registries [25, 26,
29, 30]. In our study and in Prevention of thromboembolic events –
European Registry in Atrial Fibrillation (PREFER in AF), more than half
of the highly symptomatic patients (EHRA III-IV) was not medicated with
rhythm control therapy [31].
In the Balkan region HF was an independent predictor of decreased use of
rhythm control strategy. This was also seen in other registry [27].
Of note, catheter ablation based rhythm control compared with amiodarone
therapy significantly reduces AF recurrences and re-hospitalizations and
improves quality of life in AF patients with HF [2, 32].