Rhythm vs. rate control for treatment of postoperative atrial fibrillation after cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND

We aimed to compare the clinical impact of treatment with a rhythm control strategy to a rate control strategy in postcardiac surgery atrial fibrillation patients.

METHODS

A comprehensive search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, Scopus, ProQuest Dissertations, and ClinicalTrials.gov was conducted from inception to October 2025. Our meta-analysis included randomized controlled trials (RCTs) comparing therapeutic rhythm control interventions with rate control interventions. We used the Cochrane risk-of-bias tool to appraise the quality of included RCTs, the GRADE framework to evaluate the strength of the evidence, and adhered to the PRISMA guidelines for reporting.

RESULTS

Eight RCTs (n = 894 patients) met the inclusion criteria. There was no difference in hospital length of stay (4 RCTs) between rhythm control and rate control [MD: -0.41 days (95% CI: -3.23, 2.42)]. An aggressive rhythm control strategy (ibutilide, procainamide, propafenone, or electric cardioversion) was associated with higher odds of in-hospital conversion to sinus rhythm [OR: 4.01 (95% CI: 1.30, 12.39)] and a higher risk of medication-related adverse events (hypotension, bradycardia, and syncope) [RR: 3.05 (95% CI: 1.05, 8.89)].

CONCLUSION

Among postcardiac surgery patients with new-onset atrial fibrillation, there was no evidence that a rhythm control treatment strategy resulted in better outcomes than a rate control strategy.

SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD42019128559, identifier CRD42019128559.