How to Choose Between Rate Control and Rhythm Control for Atrial Fibrillation — Video Interview with Dr. Eric Prystowsky

How to Choose Between Rate Control and Rhythm Control for Atrial Fibrillation — Video Interview with Dr. Eric Prystowsky

By Mellanie True Hills

July 17, 2012

  • Summary: Dr. Eric Prystowsky, world-renowned electrophysiologist, tackles the controversial issue of which atrial fibrillation patients should be on rate control and which should be on rhythm control.
  • Reading and watching time is approximately 9 minutes

In this video interview at Heart Rhythm 2012, Dr. Eric Prystowsky discusses the use of rate control vs. rhythm control in treating afib, including tackling the issue of whether to leave patients in atrial fibrillation and on rate control long term. He also talks about how a new afib patient, and their spouse, can partner with their physician to understand and treat their afib.

View the video interview with Dr. Prystowsky (approximately 9 minutes)

See our 2009 video interview with Dr. Prystowsky, Noted Electrophysiologist Discusses Atrial Fibrillation Guidelines

About Eric Prystowsky, MD:

Electrophysiologist, St. Vincent’s Hospital, Indianapolis, IN

For more information, see Dr. Prystowsky’s profile

Video Transcript:

Mellanie True Hills: Dr. Prystowsky, you are a world authority on rate control. I’d love for you to share with the patient community your thoughts about using rate control.

Dr. Eric Prystowsky: Thank you very much, Mellanie. It’s delightful to be here with you. Rate control is fine, for the right people, and for the right time in their lives. The problem is that people think that rate control is the preferred therapy, and that is actually wrong.

Rate vs. rhythm is an important decision for the clinician to make for a patient. The problem is that I see too many patients who have been left on rate control only. And yes, they are controlled, but they are not necessarily doing well. They may be tired, fatigued, if they have heart failure they may not be doing as well in their heart failure, and there are other things. When you’re rate controlled, you’re still not in a regular rhythm, you don’t have atrial contraction, and there have been studies showing that there is possibly some sub-clinical damage to the brain, including issues with stroke and dementia.

For big things, in trials it has been proven that mortality and stroke risk, with appropriate anticoagulation, is not materially different between rate and rhythm. But people often just don’t feel well, and the problem is that the clinician taking care of them will often take a pass on this, and the patients, if they are not savvy, think, “That’s my doctor, and this is fine.” Then they come to me a year later, when their top chamber has got fibrosis, and it’s a struggle to get them into sinus, and everyone is upset. So I wish doctors, and this is an important message for patients — you have to take charge of this, you have to ask, “Is this the best for me?” Because if you wait too long, it’s too late, and it’s very important to make that decision.

And you asked me about rate control in general. If you’re an elderly patient, and you’re totally asymptomatic, I may just go with rate control. But if you are active, and getting up and around, and especially if you’re a little fatigued — all these little subtle things — I will almost always try rhythm control as my primary therapy.

Hills: So, do you consider a year, two years, three years — what do you consider is the length of time that typically a patient needs to go to determine whether they’re really comfortable on rate control and should stay on it long-term?

Dr. Prystowsky: No, and you and I have spoken about this before — that’s the problem. No one knows exactly when the key point of fibrosis in the top chambers occurs, but it is an ongoing process. If you stay in atrial fibrillation for a long period of time — and I mean a year, two years, three years — there is an ever-present and ever-ongoing laying down of fibrous tissue in your atrium. This is irreversible, and there will be a point of no-return, or you’ll do something heroic to bring it back by a massive ablation procedure or operation. Don’t let it go that long.

My point is, don’t let it go a year. I think that it’s a critical decision to make in the first couple months of being evaluated. Now that’s not waiting too long, but a year IS too long, in my opinion. If you’re not sure, here’s what I do with my patients. I say, “Look, I know you’re saying you don’t have too many symptoms; let’s just try a trial of rhythm control.” It is not uncommon at all for patients to say, “Doc, I’ve never felt this good!” You know why? We’re all products of our own being. In other words, if you have chronic back pain, after a while, it just becomes what you have. If it suddenly went away, you’re like, “I can do this, and I can do that, what happened to me? Oh, my back pain is gone!” What happens with afib, not uncommonly, is they say, “Doc, what did you do, I just feel better!” And it wasn’t rapid palpitations or shortness of breath; it was a malaise feeling that they’ve come to accept as that’s who they are. And suddenly, Mellanie, they’re a new person! So don’t miss that opportunity!

Now, I will say this: If I have an older person, they’ve had good rate control, they claim not to be symptomatic, and I give them a chance at sinus rhythm, and they truly don’t feel a difference, I’ll let them go back to rate control. But I like to give those patients a chance to see how sinus is.

Hills: Absolutely. And you touch on something that I think is really important, and that is the area of being symptomatic. Many times, patients are identified as being asymptomatic, but maybe it’s a case that the patients haven’t recognized that they have the symptoms — the inability to walk up the stairs, getting out of breath when they try to do the simplest things, just feeling in a fog all the time — those can actually be symptoms that can be related to the afib, or potentially to the rate control medication. So in many cases, patients really are symptomatic but they don’t recognize it, or they are telling their doctors that they are not symptomatic when they really perhaps are. Can you address that?

Dr. Prystowsky: You’re spot on — that’s a very, very important point you raised, Mellanie, and thank you for doing that. The subtle signs of afib are amazing. I have had so many patients come to me, and they say, “I’m not sure why I’m here, Doc. My primary care physician has picked up an irregular pulse and I’m supposed to be here.” I find it incredibly important to talk to the spouse. Now, I will tell you this up front, if the spouse is a man and the woman is the patient, it’s not usually that much of a big deal because the woman will usually be upfront and tell you what their symptoms are.

Most guys do not — probably me included. The typical scenario in the office is, the guy says, “Well, Dr. Prystowsky, I really don’t know why I’m here. You know, they picked up this irregular pulse.” And then you watch the wife in the corner starting to seethe. She says, “You know, for the last three months, you tell me you get short of breath and tired when you do the lawn; you don’t want to do this, you don’t want to do that,” and often these are the subtle signs. When someone has their palpitations and their heart is racing, they come in to see you. But when it’s just a little in a fog, or “I don’t know, I don’t quite have the energy,” especially in your late 60s or early 70s, and you just think that maybe this is what it’s all about when I get older. But those are often the signs of afib, and they can be turned around. And it’s really simple to test the waters. You don’t have to commit yourself to rhythm control for the rest of your life, you just have to have a period of time to switch therapies, and if you’re suddenly feeling great, then you know those symptoms were due to afib.

Hills: Right, absolutely. And you bring up another important point — always, if possible, have an advocate with you at a doctor appointment because many times, they see the things that the patient doesn’t actually see.

Dr. Prystowsky: That’s absolutely true. I’m an educator — I will really take the time in my practice to go through everything — and as good an educator as I think I am, and as many years as I have had doing this, patients don’t get it all at one time. Often the person with them takes notes and will bring up points later. And, it’s a harrowing experience when you’re in a doctor’s office, especially an arrhythmia doctor. People think they may die from this, and their heart’s bouncing around. They’re focused on some things, but not everything, so I think having an advocate there is good for two reasons. One, to help out with symptoms as far as filling in the blanks, but also, after they go out of there, to help their spouse (or whoever is there with them) re-think what the office appointment was all about. Oftentimes, the patient is just not as focused on everything — they’re anxious. It’s good to have someone not quite as anxious listening a little more acutely to the nuances to help you out later.

Hills: Absolutely. Well, Dr. Prystowsky, thank you so much for taking time in your very busy schedule here at Heart Rhythm 2012. For, this is Mellanie True Hills reporting.

Dr. Prystowsky: Thank you, Mellanie.