Rate vs. rhythm control and adverse outcomes among European patients with atrial fibrillation

Yanish Purmah,Gregory Y H Lip,Michal Mazurek,Marco Proietti,Dimitrios Tahmatzidis,Salvatore Novo,Cecilé Laroche,Giuseppe Boriani

doi:10.1093/europace/euw421

Abstract

The impact of rate and rhythm control strategies on outcomes in patients with atrial fibrillation (AF) remains controversial. Our aims were: to report use of rate and rhythm control strategies in European patients from the EURObservational Research Program AF General Pilot Registry. Secondly, to evaluate outcomes according to assigned strategies. Use of pure rate and rhythm control agents was described according to European regions. 1-year follow-up data were reported. Among rate control strategies, beta-blockers were the most commonly used drug. Proportions of patients assigned to rhythm control varied greatly between countries, and amiodarone was the most used rhythm control drug. Of the original 3119 patients, 1036 (33.2%) were assigned to rate control only and 355 (11.4%) to rhythm control only. Patients assigned to a rate control strategy were older (P < 0.0001) and more likely female (P = 0.0266). Patients assigned to a rate control strategy had higher rates for any thrombo-embolic event (P = 0.0245), cardiovascular death (P = 0.0437), and all-cause death (P < 0.0001). Kaplan-Meier analysis showed that rate control strategy was associated with a higher risk for all-cause death (P < 0.001). On Cox regression analysis, rate control strategy was independently associated with all-cause death (P = 0.0256). A propensity matched analysis only found a trend for the association between rate control and all-cause death (P = 0.0664). In a European AF patients' cohort, a pure rate control strategy was associated with a higher risk for adverse events at 1-year follow-up, and partially adjusted analysis suggested that rate control independently increased the risk for all-cause death. A fully adjusted propensity score matched analysis found that this association was no longer statistically significant, suggesting an important role of comorbidities in determining the higher risk for all-cause death.

Highlights

Apart from stroke prevention, another important aspect of atrial fibrillation (AF) management involves symptom control with the physician having to decide whether to employ a rate control, rhythm control or a combination strategy with regard to each individual AF patient
In a European AF patients’ cohort, a pure rate control strategy was associated with a higher risk for adverse events at 1-year follow-up, and partially adjusted analysis suggested that rate control independently increased the risk for all-cause death
A fully adjusted propensity score matched analysis found that this association was no longer statistically significant, suggesting an important role of comorbidities in determining the higher risk for all-cause death

Summary

Introduction

Apart from stroke prevention, another important aspect of atrial fibrillation (AF) management involves symptom control with the physician having to decide whether to employ a rate control, rhythm control or a combination strategy with regard to each individual AF patient. Multiple randomized controlled trials (RCTs) comparing rate and rhythm control therapies in patients with AF have not demonstrated any evidence of superiority in terms of death or systemic embolism with either strategy.[3,4,5,6,7] Other studies have suggested contradictory results with lower mortality shown with rhythm control compared with rate control.[8,9,10] One issue with the large trials comparing rhythm vs rate control strategies has been the low rate of sinus rhythm restoration and maintenance. In the RACE study, for example, less than 40% of patients were in sinus rhythm at the end of the study.[5]

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