Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure
Denis Roy, M.D., Mario Talajic, M.D., Stanley Nattel, M.D., D. George Wyse, M.D., Ph.D., Paul Dorian, M.D., Kerry L. Lee, Ph.D., Martial G. Bourassa, M.D., J. Malcolm O. Arnold, M.D., Alfred E. Buxton, M.D., A. John Camm, M.D., Stuart J. Connolly, M.D., Marc Dubuc, M.D., Anique Ducharme, M.D., M.Sc., Peter G. Guerra, M.D., Stefan H. Hohnloser, M.D., Jean Lambert, Ph.D., Jean-Yves Le Heuzey, M.D., Gilles O'Hara, M.D., Ole Dyg Pedersen, M.D., Jean-Lucien Rouleau, M.D., Bramah N. Singh, M.D., D.Sc., Lynne Warner Stevenson, M.D., William G. Stevenson, M.D., Bernard Thibault, M.D., Albert L. Waldo, M.D., for the Atrial Fibrillation and Congestive Heart Failure Investigators
Background It is common practice to restore and maintain sinusrhythm in patients with atrial fibrillation and heart failure.This approach is based in part on data indicating that atrialfibrillation is a predictor of death in patients with heartfailure and suggesting that the suppression of atrial fibrillationmay favorably affect the outcome. However, the benefits andrisks of this approach have not been adequately studied.
Methods We conducted a multicenter, randomized trial comparingthe maintenance of sinus rhythm (rhythm control) with controlof the ventricular rate (rate control) in patients with a leftventricular ejection fraction of 35% or less, symptoms of congestiveheart failure, and a history of atrial fibrillation. The primaryoutcome was the time to death from cardiovascular causes.
Results A total of 1376 patients were enrolled (682 in the rhythm-controlgroup and 694 in the rate-control group) and were followed fora mean of 37 months. Of these patients, 182 (27%) in the rhythm-controlgroup died from cardiovascular causes, as compared with 175(25%) in the rate-control group (hazard ratio in the rhythm-controlgroup, 1.06; 95% confidence interval, 0.86 to 1.30; P=0.59 bythe log-rank test). Secondary outcomes were similar in the twogroups, including death from any cause (32% in the rhythm-controlgroup and 33% in the rate-control group), stroke (3% and 4%,respectively), worsening heart failure (28% and 31%), and thecomposite of death from cardiovascular causes, stroke, or worseningheart failure (43% and 46%). There were also no significantdifferences favoring either strategy in any predefined subgroup.
Conclusions In patients with atrial fibrillation and congestiveheart failure, a routine strategy of rhythm control does notreduce the rate of death from cardiovascular causes, as comparedwith a rate-control strategy. (ClinicalTrials.gov number, NCT00597077
[ClinicalTrials.gov]
.)
Source Information
From the Montreal Heart Institute and the Université de Montréal, Montreal (D.R., M.T., S.N., M.G.B., M.D., A.D., P.G.G., J.L., J.-L.R., B.T.); Libin Cardiovascular Institute, Calgary, AB, Canada (D.G.W.); St. Michael's Hospital, Toronto (P.D.); Duke University Medical Center, Durham, NC (K.L.L.); London Health Sciences Center, London, ON, Canada (J.M.O.A.); Rhode Island Hospital–Lifespan Academic Center, Providence, RI (A.E.B.); St. George's Hospital Medical Center, London (A.J.C.); Population Health Research Institute, Hamilton, ON, Canada (S.J.C.); J.W. Goethe University, Frankfurt, Germany (S.H.H.); Hôpital Européen Georges Pompidou, Paris (J.-Y.L.H.); Institut de Cardiologie de Québec, QC, Canada (G.O.); Bispebjerg University Hospital, Copenhagen (O.D.P.); Veterans Affairs Medical Center–West Los Angeles, Los Angeles (B.N.S.); Brigham and Women's Hospital, Boston (L.W.S., W.G.S.); and University Hospitals Case Medical Center, Cleveland (A.L.W.).
Address reprint requests to Dr. Roy at the Montreal Heart Institute, 5000 Belanger St., Montreal, QC H1T 1C8, Canada, or at d_roy{at}icm-mhi.com.
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