Rhythm vs Rate Control Strategies for Perioperative Atrial Fibrillation After Noncardiac Surgery: A Systematic Review and Meta-analysis

Background: For patients with perioperative atrial fibrillation (POAF) after noncardiac surgery, earlier conversion to sinus rhythm might improve outcomes. The efficacy of a rhythm vs rate control strategy for the acute management of POAF remains uncertain. Methods: We searched databases for randomized controlled trials (RCTs) and observational studies that included patients with POAF after noncardiac surgery and reported outcomes for patients acutely treated with a rhythm control strategy vs either a rate control or no treatment strategy. Studies were pooled using random effects models. Results: Of the observational studies, a rhythm control strategy was associated with higher conversion rates to sinus rhythm compared with a rate control or no treatment strategy (risk ratio [RR], 1.93; 95% confidence interval [CI], 1.25-2.97; 9 studies; N = 591). Compared with a rate control or no treatment strategy, a rhythm control strategy was not associated with differences in length of hospital stay (mean difference, -1.67 days; 95% CI, -7.10 to 3.76; 2 studies), length of intensive care stay (mean difference, -1.90 days; 95% CI, -7.62 to 3.82; 1 study), or all-cause mortality (RR, 1.12; 95% CI, 0.62-2.00; 5 studies). In an RCT that compared amiodarone vs magnesium, the RR was 0.56 for conversion to sinus rhythm (95% CI, 0.31-1.03; N = 34). Conclusions: A rhythm control strategy was associated with greater success rates for conversion to sinus rhythm compared with a rate control or no treatment strategy. However, the observational studies were of low quality and only 1 small RCT was identified, and few data were available for other outcomes.