Role of Rhythm Control in Prevention of Recurrent Stroke

We congratulate Conkbayır and colleagues for their study which concluded that rhythm control strategy is associated with decreased rates of recurrent stroke. ¹

There are several issues to address in this article. The average age of study population is ≤65 years. Atrial fibrillation (AF) is more problematic in elderly patients because it may be difficult to maintain sinus rhythm especially after cardioversion. ² This frail population has increased risk of bleeding with anticoagulation. ³ Another point is administration of high oral doses of amiodarone for maintenance of sinus rhythm. Amiodarone has several side effects precluding its long-term use with high rates of discontinuation. ⁴ This could explain high rates of AF in the rhythm control group. In addition, 24-hour or longer ambulatory electrocardiogram recordings might have detected asymptomatic recurrences. Time in therapeutic range (TTR) is an important measure which indicates quality of warfarin treatment. Low rate of TTR was associated with increased stroke risk. ⁵ This parameter may play a role in clinical outcomes of this study.

Rhythm control strategy did not result in decreased risk of stroke compared with rate control strategy, ⁶ but further research may define the role of rhythm control strategy for secondary prevention of stroke in era of catheter ablation and novel anticoagulants.