Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure

Montreal Heart Institute and the Université de Montréal, Montreal, QC H1T 1C8, Canada.
New England Journal of Medicine (Impact Factor: 55.87). 07/2008; 358(25):2667-77. DOI: 10.1056/NEJMoa0708789
Source: PubMed


It is common practice to restore and maintain sinus rhythm in patients with atrial fibrillation and heart failure. This approach is based in part on data indicating that atrial fibrillation is a predictor of death in patients with heart failure and suggesting that the suppression of atrial fibrillation may favorably affect the outcome. However, the benefits and risks of this approach have not been adequately studied.
We conducted a multicenter, randomized trial comparing the maintenance of sinus rhythm (rhythm control) with control of the ventricular rate (rate control) in patients with a left ventricular ejection fraction of 35% or less, symptoms of congestive heart failure, and a history of atrial fibrillation. The primary outcome was the time to death from cardiovascular causes.
A total of 1376 patients were enrolled (682 in the rhythm-control group and 694 in the rate-control group) and were followed for a mean of 37 months. Of these patients, 182 (27%) in the rhythm-control group died from cardiovascular causes, as compared with 175 (25%) in the rate-control group (hazard ratio in the rhythm-control group, 1.06; 95% confidence interval, 0.86 to 1.30; P=0.59 by the log-rank test). Secondary outcomes were similar in the two groups, including death from any cause (32% in the rhythm-control group and 33% in the rate-control group), stroke (3% and 4%, respectively), worsening heart failure (28% and 31%), and the composite of death from cardiovascular causes, stroke, or worsening heart failure (43% and 46%). There were also no significant differences favoring either strategy in any predefined subgroup.
In patients with atrial fibrillation and congestive heart failure, a routine strategy of rhythm control does not reduce the rate of death from cardiovascular causes, as compared with a rate-control strategy. ( number, NCT00597077.)

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Available from: Ole Dyg Pedersen, Feb 26, 2015
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    • "Multicenter clinical trials (AFFIRM, PIAF, RACE, HOT-CAFE, AF-CHF) did not prove that rhythm control improves survival over rate control. It has been shown, however, that restoring sinus rhythm (SR) improves the hemodynamic function of the heart and reduces the symptoms [7] [8] [9] [10] [11]. ATHENA trial results suggest that SR maintenance improves the prognosis in AF patients [11]. "
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    ABSTRACT: We assessed the value of left atrium speckle tracking imaging (STI) indices, and clinical and other echocardiographic parameters in persistent atrial fibrillation (AF) patients to predict the efficacy of electrical cardioversion (EC) and sinus rhythm (SR) maintenance at 6 months. Eighty persistent AF patients planned to receive EC, underwent echocardiography including STI. After 24h, patients with successful EC were examined to predict SR maintenance. After 6 months patients with no AF recurrence in electrocardiogram (ECG) underwent 7-day ECG to exclude silent AF. Every AF>1min was a recurrence. SR restored in 61 patients, 19 unsuccessful. Prior use of statins (68.8% vs. 42.1%, p=0.03) was the only factor, determined later by univariate analysis to be a significant EC success predictor (OR=1.09, CL±95% 1.001-1.019, p<0.03). Both groups received similar antiarrhythmics and had similar echocardiographic parameters. After 6 months, SR was maintained in 19 patients (31.1%, Group I); AF recurrences were registered in 42 patients (68.8%, Group II). In Group I, only the mitral valve deceleration time (MVDT) 224.18±88.13 vs. 181.6±60.6 in Group II, p=0.04) and the dispersion of time to peak longitudinal strain (dTPLS) (86.0±68.3 vs. 151.8±89.6, p=0.03) differed significantly. The univariate analysis revealed dTPLS as a significant predictor of SR maintenance. High EC efficacy and frequent AF recurrences were observed. The dispersion of time to the maximal longitudinal strain (LS) of left atrial segments facilitated prediction of SR maintenance. The value of 7-day ECG monitoring for detection of arrhythmia after 6 months was limited.
    Preview · Article · Mar 2014 · Advances in Medical Sciences
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    • ", and the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial did not demonstrate a benefit to a strategy of rhythm-control using antiarrhythmic drugs versus rate-control [4] [5], and consequently impacted clinical guidelines and practice [6]. Post-hoc analyses of the AFFIRM data have shown that the presence of sinus rhythm was associated with improved survival whereas antiarrhythmic drugs were associated with increased mortality [7]. "

    Full-text · Article · Nov 2013 · International journal of cardiology
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    • "Rate control therapies are favored by European and North American Guidelines as first line therapy [94] [125]. Rate control is not inferior to rhythm control therapies in terms of stroke prevention, mortality reduction and even better than rhythm control in reducing risk of hospitalization and reducing costs [129] [130] [131] [132] [133]. This review has some limitations. "
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    ABSTRACT: Background: Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia. In developing countries, AF is a growing public health problem with the epidemiologic transition from communicable to non-communicable diseases. However, relatively little is known about AF in the developing world. The aim of this review is to examine in developing countries the prevalence, associated medical conditions and management of AF. Methods: A literature search was conducted via MEDLINE and EMBASE (1990-2012). Results: Seventy studies were included in the review. The prevalence of AF in the general population ranged from 0.03% to 1.25%, while the prevalence of AF in hospital-based studies varied from 0.7% to 55.7%. Prevalence of AF in Africa was lower than in other regions. The most common conditions associated with AF were hypertension (10.3%-71.9%) and valvular heart disease (5.6%-66.3%). The prevalence of stroke in patients with AF ranged from 6.7% to 27%. The utilization of anticoagulants was highly variable (2.7%-72.7%). Approximately half of the patients with AF using warfarin had therapeutic International Normalized Ratios (INR). There was a high prevalence of use of rate control therapies (55.3%-87.3%). Conclusions: The limited studies available suggest that in the developing world there is a significant prevalence of AF, which is predominantly associated with hypertension and valvular heart disease, and carries a risk of stroke. Highly variable use of anticoagulants may be related to different health care and socioeconomic settings. More studies are needed to improve understanding of the epidemiology and management of AF in developing countries.
    Full-text · Article · Feb 2013 · International journal of cardiology
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