CTS trials network: Rate control vs rhythm control for atrial fibrillation after cardiac surgery - Do bitter pills have blessed effects?

Ahmed Afifi

doi:10.21542/gcsp.2016.15

Abstract

New onset AF is a very common sequel of cardiac surgery with an incidence reaching 50% in some studies. This post-operative complication leads to increased morbidity, hospital stay and, consequently, hospital costs1. Currently there is a great variability in the management of this condition. Despite efforts to produce best practice guidelines2, what best to do for a patient who develops AF post-operatively remains a question. In a systematic attempt to find an answer to this question, the Cardiothoracic Trials Network have recently published the results of their trial “Rate Control Versus Rhythm Control for Atrial Fibrillation After Cardiac Surgery”3 (clinicaltrials.gov number: NCT02132767).

Highlights

The trial was conducted in 23 centers in North America
At 60 days, 94% of the rate-control group and 98% of the rhythm control group were in steady sinus rhythm for a month (P=0.02) and respectively 84% and 87% had been free
GCSP 2016:15 from AF since discharge. This shows that new onset AF is a common post-operative finding, and a self-limiting disease that has tendency to resolve whichever way it is initially treated

Summary

INTRODUCTION

The trial was conducted in 23 centers in North America. Over a period of one year 2,109 patients with similar base-line characteristics undergoing CABG and/or valve surgery without prior AF were enrolled. 695 (33%) of them had postoperative new onset AF (lasting for more than 60 minutes within one week of the operation), and of these, 523 were randomized to receive either rate or rhythm control. 695 (33%) of them had postoperative new onset AF (lasting for more than 60 minutes within one week of the operation), and of these, 523 were randomized to receive either rate or rhythm control. Patients in the rhythm-control group were treated mainly with amiodarone in addition to a rate-slowing agent when found necessary and electrical cardioversion was performed if atrial fibrillation persisted for 24 to 48 hours (Figure 1). The primary outcome, number of days in the hospital, 60 days after randomization, did not differ between groups (median, 5.0 days for rhythm control and 5.1 days with rate control; P = 0.76) neither did the number of hospital readmissions. At hospital discharge 89.9% of the patients in the rate-control group and 93.5% in the rhythm-control group were without atrial fibrillation.

DISCUSSION

Findings

WHAT HAVE WE LEARNED?