Atrial fibrillation (AF) is the most common arrhythmia of all, with a prevalence of 1-2% – over six million people suffer from it in Europe alone.
The risk of developing VCF increases with age. Accordingly, it can be assumed that the prevalence will double within the next 50 years due to steadily increasing life expectancy [1].
Atrial fibrillation, as a rhythm disorder itself, is not life-threatening, but it is associated with increased morbidity and mortality rates, which is why effective treatment of atrial fibrillation is an increasing focus of interest [2, 3].
The treatment of atrial fibrillation is not only time-consuming, but also associated with high costs. Basically, two different therapeutic approaches are distinguished, frequency control and rhythm control; both strategies include optimal thromboembolism prophylaxis with anticoagulants. Contrary to the expectations of many, study results suggest that rhythm control, i.e., restoration and maintenance of sinus rhythm, may not show an advantage over frequency control with respect to cardiovascular events. However, in younger patients (<65 years), rhythm control appears to be associated with significantly lower mortality and risk of heart failure development [4].
Compared to rhythm control, frequency control can be considered as a kind of compromise solution when patients are still symptomatic. Such willingness to compromise is not new in contemporary cardiovascular medicine; it is the development of more minimally invasive technologies that has fostered the willingness to compromise with respect to achieving the therapeutic goal. For example, since the introduction of minimally invasive treatment of aortic valve stenosis using a transcatheter valve, residual aortic regurgitation due to a paravalvular prosthetic leak has been accepted [5]. It is all the more surprising that many colleagues are surprised that this problem negatively affects the patient’s long-term risk.
We see a similar phenomenon in transcatheter mitral valve intervention, where residual mitral regurgitation or “iatrogenically” developed mitral stenosis is associated with increased mortality in treated patients [6].
Cardiac surgery, often equated with “maximum invasiveness,” is also moving toward less traumatic techniques. However, the therapeutic goal of cardiac surgery remains the complete rehabilitation of the diseased condition. Patients and referring physicians rely on the fact that an openly surgically installed heart valve functions perfectly or that blood flow to the heart muscle is improved in the long term after an aorto-coronary bypass. Why don’t we have similar requirements for atrial fibrillation therapy? Would you rather have rate-controlled atrial fibrillation or sinus rhythm after all?
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PD Alberto Weber, MD
