Abstract
In the past 20 years the Netherlands-based RACE trials have investigated important concepts in clinical atrial fibrillation (AF). Their scope ranged from rhythm versus rate control to early or delayed cardioversion and also included early comprehensive management of AF in two trials, one focusing on early ‘upstream therapy’ and risk factor management and the other on integrated chronic nurse-led care. Studies were mostly triggered by simple clinical observations including futility of electrical cardioversion in persistent AF; many patients with permanent AF tolerating day-after-day ‘uncontrolled’ resting heart rates of up till 110 beats/min; patients being threatened more by vascular risks than AF itself; and insufficient guideline-based treatments for AF. Also the observation that recent-onset atrial fibrillation generally converts spontaneously, obviating cardioversion, triggered one of the studies. The RACE trials shifted a number of paradigms and by that could change the AF guidelines. The initial ‘shock-and-forget’ attitude made place for increased attention for anticoagulation, and in turn, broader vascular risks were recognised. In a nutshell, the adage eventually became: ‘look beyond the ECG, treat the patient’.Electronic supplementary materialThe online version of this article (10.1007/s12471-020-01476-0) contains supplementary material, which is available to authorized users.
Highlights
The first RACE study [1] originated from the Academic Hospital Groningen and spread rapidly across the Netherlands
A post-hoc comparison of the rate control arms of RACE and AFFIRM showed a significantly lower heart rate but a higher composite of cardiovascular death, hospitalisation and myocardial infarction in AFFIRM compared with RACE (34 vs 25%) and conspicuously more patients in need of pacemaker therapy (11 vs 1% over 3 years, p < 0.009) [28]
Once atrial fibrillation (AF) emerges, most patients already suffer from vascular remodelling. These notions were fed by remarkable findings from studies such as the LIFE trial [35] indicating that at similar blood pressure reduction in hypertensive patients suffering from left ventricular hypertrophy, the angiotensin receptor blocker (ARB) losartan halved the incidence of AF compared with the beta
Summary
The first RACE study [1] originated from the Academic Hospital Groningen and spread rapidly across the Netherlands. Upon atrial fibrillation (AF) as an arrhythmia for which rhythm control, especially antiarrhythmic drugs and electrical cardioversion (ECV), were most important (‘shock-and-forget’). We asked investigators to maximise efforts to keep patients in sinus rhythm by performing repeat cardioversion as quickly as possible after a recurrence and tailor antiarrhythmic drug treatment to the patient, avoiding both underdosing as well as side effects. During those years catheter ablation was not widely used for AF. A non-electrical primary endpoint was chosen in RACE since it is not the eventual rhythm during follow-up that counts but rather longevity of the patient and avoiding severe adverse events including heart failure, stroke, bleed-
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