A comparison of rate control and rhythm control in patients with atrial fibrillation.

BACKGROUND There are two approaches to the treatment of atrial fibrillation: one is cardioversion and treatment with antiarrhythmic drugs to maintain sinus rhythm, and the other is the use of rate-controlling drugs, allowing atrial fibrillation to persist. In both approaches, the use of anticoagulant drugs is recommended. METHODS We conducted a randomized, multicenter comparison of these two treatment strategies in patients with atrial fibrillation and a high risk of stroke or death. The primary end point was overall mortality. RESULTS A total of 4060 patients (mean [+/-SD] age, 69.7+/-9.0 years) were enrolled in the study; 70.8 percent had a history of hypertension, and 38.2 percent had coronary artery disease. Of the 3311 patients with echocardiograms, the left atrium was enlarged in 64.7 percent and left ventricular function was depressed in 26.0 percent. There were 356 deaths among the patients assigned to rhythm-control therapy and 310 deaths among those assigned to rate-control therapy (mortality at five years, 23.8 percent and 21.3 percent, respectively; hazard ratio, 1.15 [95 percent confidence interval, 0.99 to 1.34]; P=0.08). More patients in the rhythm-control group than in the rate-control group were hospitalized, and there were more adverse drug effects in the rhythm-control group as well. In both groups, the majority of strokes occurred after warfarin had been stopped or when the international normalized ratio was subtherapeutic. CONCLUSIONS Management of atrial fibrillation with the rhythm-control strategy offers no survival advantage over the rate-control strategy, and there are potential advantages, such as a lower risk of adverse drug effects, with the rate-control strategy. Anticoagulation should be continued in this group of high-risk patients.

[1]  G. Rose,et al.  RISK OF STROKE IN NON-RHEUMATIC ATRIAL FIBRILLATION , 1987, The Lancet.

[2]  B. Yawn,et al.  Trends in the Incidence and Survival of Patients with Hospitalized Myocardial Infarction, Olmsted County, Minnesota, 1979 to 1994 , 2002, Annals of Internal Medicine.

[3]  D.,et al.  Regression Models and Life-Tables , 2022 .

[4]  J. Gardin,et al.  Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study). , 1994, The American journal of cardiology.

[5]  P. Wolf,et al.  Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. , 1987, Archives of internal medicine.

[6]  A. Waldo.  MANAGEMENT OF ATRIAL FIBRILLATION : THE NEED FOR AFFIRMATIVE ACTION , 1999 .

[7]  D. Levy,et al.  Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. , 1998, Circulation.

[8]  Mark D. Carlson,et al.  Atrial Fibrillation: A Risk Factor for Increased Mortality – An AVID Registry Analysis , 2001, Journal of Interventional Cardiac Electrophysiology.

[9]  Hakan Oral,et al.  Pulmonary Vein Isolation for Paroxysmal and Persistent Atrial Fibrillation , 2002, Circulation.

[10]  Lung.  Atrial fibrillation: Current understandings and research imperatives , 1993 .

[11]  S. Hohnloser,et al.  Rhythm or rate control in atrial fibrillation—Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial , 2000, The Lancet.

[12]  I. V. Van Gelder,et al.  Serial antiarrhythmic drug treatment to maintain sinus rhythm after electrical cardioversion for chronic atrial fibrillation or atrial flutter. , 1991, The American journal of cardiology.

[13]  R. Hart,et al.  Atrial Fibrillation and Thromboembolism: A Decade of Progress in Stroke Prevention , 1999, Annals of Internal Medicine.

[14]  K. K. Lan,et al.  Discrete sequential boundaries for clinical trials , 1983 .

[15]  A. Curtis,et al.  Frequency of Symptomatic Atrial Fibrillation in Patients Enrolled in the Atrial Fibrillation Follow‐up Investigation of Rhythm Management (AFFIRM) Study , 2002, Journal of cardiovascular electrophysiology.

[16]  Z. Blanck,et al.  Atrioventricular nodal modification and atrioventricular junctional ablation for control of ventricular rate in atrial fibrillation. , 1998, Journal of cardiovascular electrophysiology.

[17]  F A Mathewson,et al.  The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. , 1995, The American journal of medicine.

[18]  P. O'Brien,et al.  A multiple testing procedure for clinical trials. , 1979, Biometrics.

[19]  A. Laupacis,et al.  Meta-analysis of randomised controlled trials of the effectiveness of antiarrhythmic agents at promoting sinus rhythm in patients with atrial fibrillation , 2002, Heart.

[20]  P. Wolf,et al.  Epidemiologic assessment of chronic atrial fibrillation and risk of stroke , 1978, Neurology.

[21]  Marlene R. Miller,et al.  Efficacy of agents for pharmacologic conversion of atrial fibrillation and subsequent maintenance of sinus rhythm: a meta-analysis of clinical trials. , 2000, The Journal of family practice.

[22]  S. Folstein,et al.  "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. , 1975, Journal of psychiatric research.

[23]  M. Rich,et al.  Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation. , 2000, Stroke.

[24]  S. Ebrahim,et al.  Systematic review of long term anticoagulation or antiplatelet treatment in patients with non-rheumatic atrial fibrillation , 2001, BMJ : British Medical Journal.

[25]  P M Rautaharju,et al.  Cardiac arrhythmias on 24-h ambulatory electrocardiography in older women and men: the Cardiovascular Health Study. , 1994, Journal of the American College of Cardiology.

[26]  E. Kaplan,et al.  Nonparametric Estimation from Incomplete Observations , 1958 .

[27]  M. Brodsky,et al.  Amiodarone for maintenance of sinus rhythm after conversion of atrial fibrillation in the setting of a dilated left atrium. , 1987, The American journal of cardiology.

[28]  J. Pell,et al.  Trends in case-fatality in 22968 patients admitted for the first time with atrial fibrillation in Scotland, 1986-1995. , 2002, International journal of cardiology.

[29]  P A Poole-Wilson,et al.  Six minute walking test for assessing exercise capacity in chronic heart failure. , 1986, British medical journal.

[30]  S. Hohnloser,et al.  Rhythm or Rate Control in Atrial Fibrillation: Insights from the Randomized Controlled Trials , 2003, Journal of cardiovascular pharmacology and therapeutics.

[31]  P. Wolf,et al.  Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. , 1991, Stroke.

[32]  A. Belanger,et al.  The Framingham study. , 1976, British medical journal.

[33]  G. Lip,et al.  Antithrombotic therapy for atrial fibrillation , 2002, BMJ : British Medical Journal.

[34]  H. Crijns,et al.  Chronic atrial fibrillation. Success of serial cardioversion therapy and safety of oral anticoagulation. , 1996, Archives of internal medicine.

[35]  G. Kay,et al.  Clinical outcomes after ablation and pacing therapy for atrial fibrillation : a meta-analysis. , 2000, Circulation.

[36]  F. Morady,et al.  Nonpharmacological Approaches to Atrial Fibrillation , 2001, Circulation.

[37]  V. Fuster,et al.  ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conference , 2001, Circulation.

[38]  Lippincott Williams Wilkins,et al.  Stroke Prevention in Atrial Fibrillation Study: Final Results , 1991, Circulation.

[39]  D. Singer,et al.  Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. , 2001, JAMA.

[40]  J. Cox,et al.  Current status of the Maze procedure for the treatment of atrial fibrillation. , 2000, Seminars in thoracic and cardiovascular surgery.