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].