Non-pharmacological methods of maintaining sinus rhythm.

Sinus Rhythm To the Editor: The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) investigators recently presented their analysis of the relationship between cardiac rhythm, treatment, and survival from the original AFFIRM study.1 The investigators conclude that the use of warfarin and the presence of sinus rhythm were important determinants of survival. The use of antiarrhythmic drug therapy to maintain sinus rhythm did not appear to improve survival, perhaps indicating that the mortality benefit from sinus rhythm was offset by the hazards of drug therapy. Though these data are retrospective and nonrandomized, the article supports epidemiological evidence that atrial fibrillation is an independent risk factor for mortality.2 After the publication of the rate versus rhythm data, changes in the management of atrial fibrillation have been reported.3 Patients that may previously have undergone cardioversion are now being maintained in permanent atrial fibrillation. Is it possible that this strategy is actually incorrect? Finally, the authors conclude that, “If an effective method for maintaining sinus rhythm with fewer adverse effects were available, it might be beneficial” (p 1509). The patient activated atrial defibrillator is such a method and has been shown in several studies to be a safe and effective method of restoring and maintaining sinus rhythm in patients with recurrent persistent atrial fibrillation.4–6 Prolonged sinus rhythm duration between cardioversions has been observed, and patients may potentially be withdrawn from the risks of antiarrhythmic medication. With increasing evidence of the long-term hazards of atrial fibrillation and antiarrhythmic drug therapy, non-pharmacological methods of maintaining sinus rhythm are becoming more attractive.