Rhythm control improves quality of life in patients with CHF and AF

Clinical Question

In patients with chronic atrial fibrillation and heart failure, is rate control or rhythm control better at improving quality of life?

Bottom Line

Although rhythm control had no better or worse effect on mortality than rate control in patients with atrial fibrillation (AF) in addition to heart failure, quality of life may be better with rhythm control. However, conversion to sinus rhythm with amiodarone occurs infrequently and most patients will need electrical conversion. (LOE = 1b)


Shelton RJ, Clark AL, Goode K, et al. A randomised, controlled study of rate versus rhythm control in patients with chronic atrial fibrillation and heart failure: (CAFÉ-II Study). Heart 2009;95(11):924-930.  [PMID:19282313]

Study Design

Randomized controlled trial (nonblinded)


Unknown/not stated




Outpatient (specialty)


A recent study of heart failure treatment found no difference in mortality when heart rate was controlled as compared with rhythm control. But there is more to life than its length, and the British researchers conducting this randomized controlled study compared the 2 approaches in 61 patients with at least New York Heart Association class II symptoms of heart failure who also had chronic AF as defined by European and American Heart Society guidelines. Most (84%) of the patients were male with an average age of 72.4 years and heart failure of a median duration of 14 months. The patients were assigned (allocation concealment uncertain) to receive rhythm control with amiodarone, followed by electrical conversion attempts after 2 to 3 months of treatment if needed, or rate control. Both groups received beta-blockers and/or digoxin to reduce the heart rate to less than 80 bpm at rest and less than 110 bpm after walking. In the rate control group, 61% of patients reached this goal. Normal sinus rhythm was restored in 20% of patients receiving amiodarone and in 66% of these patients by the end of the year. By intention-to-treat analysis, quality of life worsened by an average 3 points (out of a possible 100 on the Medical Outcomes Study 36-Short Form Health Survey) from an average 37.3 in the rate control group, and improved by an average 6.5 points from an average of 40.7 in the the rhythm control group (P = .02). Exercise performance using the 6-minute walk test was not different between groups; neither was quality of life as measured by the Minnesota Living with Heart Failure questionnaire. When comparing only responders in each group (on protocol analysis), quality of life was significantly better using both measures.