Investigation Of Rhythm Management Research Articles

The impact of visit-to-visit heart rate variability on all-cause mortality in atrial fibrillation.

We aimed to investigate the association between visit-to-visit heart rate variability (VVHRV) and all-cause mortality in patients diagnosed with atrial fibrillation (AF). Previous studies have shown a positive correlation between VVHRV and several adverse outcomes. However, the relationship between VVHRV and the prognosis of AF remains uncertain. In our study, we aimed to examine the relationship between VVHRV and mortality rates among 3983 participants with AF, who were part of the AFFIRM study (Atrial Fibrillation Follow-Up Investigation of Rhythm Management). We used the standard deviation of heart rate (HRSD) to measure VVHRV and divided the patients into four groups based on quartiles of HRSD (1st, <5.69; 2nd, 5.69-8.00; 3rd, 8.01-11.01; and 4th, ≥11.02). Our primary endpoint was all-cause death, and we estimated the hazard ratios for mortality using the Cox proportional hazard regressions. Our analysis included 3983 participants from the AFFIRM study and followed for an average of 3.5 years. During this period, 621 participants died from all causes. In multiple-adjustment models, we found that the lowest and highest quartiles of HRSD independently predicted an increased risk of all-cause mortality compared to the other two quartiles, presenting a U-shaped relationship (1st vs 2nd, hazard ratio = 2.28, 95% CI = 1.63-3.20, p < .01; 1st vs. 3rd, hazard ratio = 2.23, 95% CI = 1.60-3.11, p < .01; 4th vs. 2nd, hazard ratio = 1.82, 95% CI = 1.26-2.61, p < .01; and 4th vs. 3rd, hazard ratio = 1.78, 95% CI = 1.25-2.52, p < .01). In patients with AF, we found that both lower VVHRV and higher VVHRV increased the risk of all-cause mortality, indicating a U-shaped curve relationship.

Abstract 14115: A Multimorbidity-based, Risk-stratified Reanalysis of the Affirm Trial

Introduction: Multimorbidity is common in patients with cardiovascular disease. Clinical trials in cardiovascular medicine mostly enroll patients who are younger, healthier and more affluent than average patients with the condition of interest. These trials rarely account for patient-level multimorbidity in a systematic fashion. Further, treatment effect heterogeneity is usually tested across subgroups of patients based on the presence or absence of individual variables, not on the basis of summative risk scores which account for multimorbidity. Objectives: To describe the distribution of multimorbidity using a modified version of the Charleson comorbidity index (mCCI), scale 0-14, and to assess its impact on the original primary endpoint of all-cause mortality. Methods: We performed a multimorbidity-based risk-stratified reanalysis of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Trial. To do this, we created a mCCI risk score based on inclusion of patient clinical parameters documented at the time of trial enrollment. The variables included in our score are: Age, ischemic heart disease, heart failure, symptomatic bradycardia, stroke or TIA, peripheral vascular disease, diabetes, hepatic or renal disease, pulmonary disease, and polypharmacy. Results: We found that the majority of patients in the AFFIRM Trial had a mCCI score of ≤4 (55.5%) and there was no statistically significant difference in the risk of death for rate vs rhythm control in these patients (7.9% vs 8.8%; p=0.44 ). However, for patients with a mCCI ≥5 (44.5%), there was a strong trend toward a reduction in death with rate control that nearly reached statistical significance despite being underpowered (24.5% vs 28.3%; p=0.07 ), figure. Conclusion: This proof-of-concept study supports the idea that clinical trials in cardiovascular medicine should systematically assess for multimorbidity and investigate its potential impact on treatment effects.

A Multimorbidity-Based, Risk-Stratified Reanalysis of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Trial.

Multimorbidity is common in patients with cardiovascular disease. Clinical trials in cardiovascular medicine mostly enroll patients who are younger, healthier, and more affluent than average patients with the condition of interest. These trials rarely account for patient-level multimorbidity in a systematic fashion. Further, treatment effect heterogeneity is usually tested across subgroups of patients based on the presence or absence of individual variables, not on the basis of summative risk scores that account for multimorbidity. Thus, the impact of multimorbidity on treatment effects is poorly understood. In this study, we performed a multimorbidity-based risk-stratified reanalysis of the AFFIRM (Atrial Fibrillation Follow-Up Investigation of Rhythm Management) trial. Our objectives were to describe the distribution of multimorbidity using a modified version of the Charlson Comorbidity Index (mCCI), scale 0-14, and to assess its impact on the original primary endpoint of all-cause mortality. The majority of patients in the AFFIRM trial had an mCCI score of ≤4 (55.5%), and there was no statistically significant difference in the risk of death for rate versus rhythm control in these patients (7.9 vs. 8.8%; p=0.44). However, for patients with an mCCI ≥5 (44.5%), there was a strong trend toward a reduction in death with rate control that nearly reached statistical significance despite being underpowered (24.5 vs. 28.3%; p=0.07). This proof-of-concept study supports the idea that clinical trials in cardiovascular medicine should systematically assess for multimorbidity and investigate its potential impact on treatment effects.

P3474Relationship between international normalized ratio variability, quality of anticoagulation control and outcomes in patients with atrial fibrillation: an AFFIRM post-hoc analysis

Abstract Introduction Quality of anticoagulation control is essential to ensure better clinical outcomes in patients with atrial fibrillation (AF). Time in therapeutic range (TTR) is recommended as a measure of the quality of anticoagulation control. The International normalized ratio (INR) variability has been suggested as an alternative index, even though large independent validations for this index are still lacking. Purpose To provide validation of clinical usefulness of INR variability as a measure of the quality of anticoagulation control in a large cohort of AF patients. Methods Data from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial were analysed. INR variability was defined as the standard deviation (SD) of mean INR values [INR-SD] recorded throughout the follow-up observation for each patient. All patients with available INR values were included in the analysis. Stroke, major bleeding, cardiovascular (CV) death and all-cause death were study outcomes. Results Among the original 4060 patients, a total of 3185 (78.4%) were available for analysis. Mean (SD) INR-SD was 0.58 (0.25). According to INR-SD patients were categorized into four quartiles. Mean (SD) CHA2DS2-VASc score was increased (p=0.040), with no difference in proportions of CHA2DS2-VASc ≥2 (p=0.582) between the subgroups. A significant inverse correlation was found between INR-SD and TTR (Spearman's Rho: −0.536, p&lt;0.001). Continuous INR-SD, after multiple adjustments, was inversely associated with TTR (standardized beta: −0.451, p&lt;0.001) and directly associated with SAMe-TT2R2score (standardized beta: 0.084, p&lt;0.001). A fully adjusted Cox multivariate regression analysis found that INR-SD was directly associated with increased risk of stroke, major bleeding and all-cause death (Table). An INR-SD ≥0.85 was directly associated with all the study outcomes, on multivariate analysis (Table). Cox Regression Analysis INR-SD INR-SD ≥0.85 HR (95% CI) HR (95%) Stroke 2.52 (1.34–4.67) 1.62 (1.00–2.63) Major Bleeding 2.43 (1.49–3.96) 1.61 (1.10–2.36) CV Death 1.50 (0.87–2.59) 1.54 (1.07–2.24) All-Cause Death 1.79 (1.21–2.66) 1.55 (1.17–2.05) CI = Confidence Interval; CV = Cardiovascular; HR = Hazard Ratio; INR-SD = International Normalized Ratio Standard Deviation. Conclusions INR variability, expressed as INR-SD, was significantly correlated and associated with TTR. Both continuous INR-SD and INR-SD ≥0.85 were significantly associated with a higher risk of all study adverse outcomes. Acknowledgement/Funding None

2258Peripheral arterial disease in a cohort of atrial fibrillation patients. The Atrial Fibrillation Follow Up Investigation Of Rhythm Management (AFFIRM) study

2258Peripheral arterial disease in a cohort of atrial fibrillation patients. The Atrial Fibrillation Follow Up Investigation Of Rhythm Management (AFFIRM) study

Non-influence of lipid lowering therapy in atrial fibrillation recurrence

Statin therapy has been associated with a reduction in ventricular and supra-ventricular tachyarrhythmias [1,2]. Statin therapy has also been associated with a lower risk of new onset AF in the elderly [3]. However, a recent meta-analysis showed reduction of secondary AF events but no reduction of new onset AF with statin use [4] .T here is considerable debate with respect to the antiarrhythmic effects of statin therapy in AF. We determined the association of lipid lowering therapy (LLT) in prevention of AF recurrence in a large high-risk patient population with AF, most of whom were on statin [5]. We performed a post hoc analysis of patients enrolled in the atrial fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. A public-use limited-access dataset that was devoid of all patient identifiers was obtained from the National Heart, Lung and Blood Institute (NHLBI). AFFIRM was a prospective trial (n = 4060) comparing survival in patients with AF and at least one risk factor for stroke randomized to a strategy of rate control (n = 2027) versus a strategy of rhythm control (n = 2033) [6,7]. Our inclusion criteria included subjects in sinus rhythm at baseline (n = 2095). The primary end point of our analysis was the time to first AF recurrence (in months). AF recurrence was determined on basis of electrocardiograms done duringeach followup visit. Follow-up datawas available at 2, 4, 8, and 12 months and then 3 visits per year until a period of 6 years or study termination. At each visit, vital signs, information onprimary or secondaryend points, medications, NYHA (New York Heart Association) class, hospitalizations and presence of documented AF or atrial flutter were collected.

OPTIMAL BLOOD PRESSURE IN PATIENTS WITH ATRIAL FIBRILLATION

The exact relationship between blood pressure (BP) and mortality is unclear in a population of patients with atrial fibrillation (AF). We performed a post hoc analysis of 3,947 participants from the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Trial. Systolic (SBP) and

Considering the changing landscape of heart failure care

British Journal of Cardiac NursingVol. 7, No. 4 Meeting ReportConsidering the changing landscape of heart failure careJayne Masters, Suzy Hughes, Jane ButlerJayne MastersSearch for more papers by this author, Suzy HughesSearch for more papers by this author, Jane ButlerSearch for more papers by this authorJayne Masters; Suzy Hughes; Jane ButlerPublished Online:27 Sep 2013https://doi.org/10.12968/bjca.2012.7.4.194AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Anker S, Colet J, Filipatos M et al. for the FAIR-HF trial investigators (2009) Ferric Carboxymaltose in patients with heart failure and iron deficiency. N Engl J Med 361: 2436–2436 Crossref, Google ScholarHjalmarson A (2007) Controlled Rosuvastatin multinational trial in heart failure (CORONA) – results of an outcomes trial in patients with ischaemic heart disease and heart failure. American heart association 2007. Scientific session; November 5 2007; Orlando Fl Late breaking trials Google ScholarNational Institute for Cardiovascular Outcomes Research (2011) National Heart Failure Audit April 2010–March 2011. http://www.ucl.ac.uk/nicor/audits/heartfailure/additionalfiles/pdfs/annualre-ports/annual11.pdf (accessed 23 March 2012) Google ScholarTavazzi L, Maggioni AP, Machioli R et al. for the Gissi -HF trial investigators (2008) Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised double blind, placebo controlled trial. Lancet 372: 1231–1231 Crossref, Google ScholarWyse DG, Waldo AL, DiMarco JP et al. (2002) A comparison of rate control and rhythm control in patients with atrial fibrillation. The atrial fibrillation follow up investigation of rhythm management (AFFIRM) investigators. N Engl J Med 347: 1825–1825 Crossref, Google Scholar FiguresReferencesRelatedDetails 1 April 2012Volume 7Issue 4ISSN (online): 2052-2207 Metrics History Published online 27 September 2013 Published in print 1 April 2012 Information© MA Healthcare LimitedPDF download

Abstract P105: Women with Atrial Fibrillation have Increased Risk of Incident Stroke: Insights from a Propensity-Matched Study of the AFFIRM Trial

Background: Women with atrial fibrillation (AF) have been reported to have poor outcomes. It remains unclear if this association is intrinsic or mediated by the higher comorbidity burden of female AF patients. Therefore, we examined the association between sex and outcomes in a balanced cohort of propensity-matched AF patients who participated in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. Methods: Of the 4060 AFFIRM patients, 1594 (39%) were women. Propensity scores for female sex were calculated for each of the 4060 patients, and were used to assemble a cohort of 1097 pairs of men and women who were balanced on 51 baseline characteristics, including major cardiovascular (CV) risk factors and medication use, including warfarin. Matched Cox regression models were used to estimate the association between female sex and outcomes during 6 years of follow-up. Results: Patients (n=4060) had a mean (±SD) age of 70 (±8) years and 13% were African American. All-cause mortality occurred in 19% and 15% of matched men and women, respectively (matched HR when women were compared to men, 0.88; 95% CI, 0.69-1.11; p=0.279). All-cause hospitalization occurred in 61% of both men and women (matched HR for women, 1.06; 95% CI, 0.93-1.21; p=0.372). Sex was not associated with CV hospitalization (matched HR for women, 1.13; 95% CI, 0.97-1.32; p=0.111). Ischemic stroke occurred in 3% and 5% of matched men and women, respectively (OR when women were compared to men, 2.02; 95% CI, 1.28-3.18; p=0.002). There was no sex-related difference in major bleeding (7% each). Conclusion: In a cohort of AF patient in which men and women were well-balanced on 51 baseline characteristics including warfarin use, women had increased risk of stroke, but there was no sex-related variation in all-cause mortality or CV hospitalization.

The value of cardiovascular hospitalization as an endpoint for clinical atrial fibrillation research

This editorial refers to ‘Cardiovascular hospitalization as a surrogate endpoint for mortality in studies of atrial fibrillation: report from the Stockholm Cohort Study of Atrial Fibrillation’ by L. Friberg and M. Rosenqvist, on page 626. Cardiovascular (CV) hospitalization has been used as a primary endpoint in clinical studies on atrial fibrillation (AF), but its value remains controversial. Cardiovascular hospitalization is associated with a decreased quality of life, 1 increased costs of care, 2 and increased risk of mortality. 3,4 However, it is also composed of a multiplicity of different clinical conditions ranging from heart failure to angina, and rates may vary among geographical regions and clinical settings. The operational definition and value of CV hospitalization as an endpoint should be well understood to draw valid conclusions in AF research. Mortality is a relevant outcome to assess the effect of therapies in AF patients. However, because death rates are low and existing therapies are effective, mortality trials are challenging to conduct. From the feasibility and cost perspective it is useful to employ surrogate and combined endpoints, but these should be well understood and validated. 5,6 Cardiovascular hospitalization is a potentially useful outcome of clinical importance. The Atrial Fibrillation Follow up Investigation of Rhythm Management (AFFIRM) investigators have shown that CV hospitalization could be a valid outcome in AF trials since it occurs prior to and more often than the true endpoint (mortality), can be objectively measured, and accurately predicted mortality independent of the application of rate or rhythm control. 3 The first time CV hospitalization or death was used as a primary outcome in a major AF trial was in the ATHENA (A placebo controlled, double blind Trial to assess the efficacy of dronedarone for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation and flutter) study, which was also the first study to demonstrate a reduction in important clinical CV outcomes with an antiarrhythmic drug (dronedarone). 7 With the Stockholm Cohort Study of Atrial Fibrillation (SCAF) analysis, Friberg and Rosenqvist 4 demonstrate an association between CV hospitalization and all-cause mortality among 2912 AF patients during a 6.5-year follow-up using a prospective observational cohort with detailed patient information. The SCAF analysis confirms the original findings of the AFFIRM analysis regarding the significant association of CV hospitalization with mortality. The strength of the association did not differ greatly from that in AFFIRM, although it depends on which SCAF analysis you look at. The AFFIRM reported a hazard ratio of 2.15 in the rhythm control group and 1.71 in the rate control group. 3 The SCAF hazard ratio for mortality during the first 3 months following hospitalization was 1.69, but decreased to 1.43 when taking into account deaths during 1 year and even to 1.35 when using a propensity score to correct for unmeasured differences between groups and improve comparability in this observational study. When adding medication use to the model of the final 2.5 years of the follow-up, the hazard ratios for mortality during 3 and 12 months were 2.08 and 1.63 respectively, which compared favourably with those observed in AFFIRM. All analyses of the SCAF verified the significance of the association of CV hospitalization and mortality, but also indicated the importance of the nature of the analysis to assess the strength of the association. Using hospitalization as an endpoint is not a new concept since hospitalization for heart failure has been widely used in heart failure research. Although any CV hospitalization is less of a disease-specific endpoint in AF research, its use as a mortality substitute seems justified considering that a two-fold increased risk for mortality associated with AF mainly relates to the presence of concomitant CV disease and risk factors. 8 The exact definition of CV hospitalization therefore needs some thought. The SCAF analysis showed that hospitalization primarily for AF was associated with lower mortality than hospitalization for other CV diagnoses. Considering that AF hospitalization was the main driver for CV hospitalization, with 44% of all hospitalizations, a treatment specifically targeting AF might lower the overall CV hospitalization rate without significantly affecting mortality. In the ATHENA study

Impact of Lipid-Lowering Therapy on Outcomes in Atrial Fibrillation

Lipid-lowering therapy (LLT) decreases mortality in select patient populations. LLT has also been shown to have antiarrhythmic effects, thus favorably influencing the incidence and recurrence of atrial fibrillation (AF). However, data are lacking regarding the effect of LLT on mortality in patients with AF. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study was the one of the largest multicenter trials comprising of 4,060 patients with AF at high risk for stroke and death. This is a post hoc analysis of the National Heart, Lung, and Blood Institute limited-access dataset of AFFIRM patients who were on LLT at the time of randomization (n = 913). The control group consisted of AFFIRM patients who were not on LLT (n = 3,147). Cox proportional hazards analysis was performed controlling for baseline differences. The end point was all-cause mortality, cardiovascular mortality, and ischemic stroke. A separate analysis was carried out for the combined end point of death, ventricular tachycardia, ventricular fibrillation, cardiac arrest, ischemic stroke, major bleeding, systemic embolism, pulmonary embolism, and myocardial infarction. Patients on LLT were younger and on more cardioactive medications but also had more cardiovascular morbidities. On multivariate analysis, LLT use was associated with lower all-cause mortality (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.62 to 0.95, p = 0.01), cardiovascular mortality (HR 0.71, 95% CI 0.53 to 0.95, p = 0.02), ischemic stroke (HR 0.56, 95% CI 0.36 to 0.89, p = 0.01), and combined end point (HR 0.81, 95% CI 0.69 to 0.96, p = 0.01). In conclusion, a decrease in mortality and adverse cardiovascular events was observed using LLT in AF.

Atrial Fibrillation and Flecainide – Safety, Effectiveness and Quality of Life Outcomes

Flecainide is a class IC antiarrhythmic agent indicated for patients with atrial fibrillation without any evidence of structural heart disease. This brief review of four recent studies on flecainide focuses on safety aspects, efficacy and the debate on impact on quality of life in this patient population. This article also briefly summarises data from the Cardiac Arrhythmia Suppression Trial (CAST) and the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study, which investigated the effect of antiarrhythmics such as flecainide on morbidity and mortality. When administered according to recommended guidelines, flecainide is safe and is not associated with increased mortality. It is effective for the treatment of atrial fibrillation, improving quality of life in these patients.

Clinical Characteristics of Patients With Persistent Atrial Fibrillation Referred for Cardioversion: Spanish Cardioversion Registry (REVERSE)

The objectives were to investigate the treatment and clinical characteristics of patients referred for cardioversion in Spain and to compare them with those reported in the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) and RACE (RAte Control versus Electrical cardioversion) studies. The prospective study involved 1515 consecutive patients with persistent atrial fibrillation who were referred for cardioversion at 96 Spanish hospitals. Half of the patients were being treated with Vaughan-Williams group-I or -III antiarrhythmic drugs. The most frequently used approach to anticoagulation was to administer dicoumarins 34 weeks before and after cardioversion. Our patients were younger than those in the AFFIRM and RACE studies. Compared with AFFIRM patients, our patients had a lower prevalence of previous embolism, ischemic heart disease, hypertension, diabetes, and systolic dysfunction. Compared with RACE patients, our patients had a lower prevalence of ischemic heart disease and previous embolism, but a slightly higher prevalence of hypertension and diabetes. We conclude that patients referred for cardioversion in Spain clearly had a lower cardiovascular risk profile than those in the AFFIRM study, and appeared to have a lower risk profile than those in the RACE study.

When, how, and why should sinus Rhythm be restored in patients with persistent atrial fibrillation?

The results of the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial indicate that the rate control strategy is preferred for the majority of patients with paroxysmal and persistent atrial fibrillation (AF). If the patient remains symptomatic despite adequate rate control or if rate control cannot be achieved, then rhythm control therapies are indicated. The most likely explanation for the disappointing results of the AFFIRM trial is the poor efficacy and excessive toxicity of rhythm control medications, because the presence of sinus rhythm was associated with a favorable prognosis in AFFIRM. As a result, there is currently great interest in nonpharmacologic therapies such as AF ablation and development of new drugs for AF with a more favorable efficacy and toxicity profile. AF ablation should be reserved for patients who fail an initial trial of a rhythm control medication until additional clinical trial information is available to justify the use of AF ablation as first-line therapy. When rhythm control therapy is indicated, the choice of antiarrhythmic medication should be dictated by the presence or absence of structural heart disease, congestive heart failure, renal dysfunction, or other comorbidities in order to maximize efficacy and minimize the chance of proarrhythmia or extracardiac toxicity.

Practical Lessons From The New Atrial Fibrillation Guidelines

INTRODUCTION Atrial fibrillation is the most common arrhythmia in the country, and its prevalence is increasing as the U.S. population ages.1 Frequently associated with hypertension and/or coronary artery disease (CAD), atrial fibrillation results in serious morbidity, mortality, hospitalization and emergency room visits. Since 2000, five clinical trials have been published regarding the question of whether the use of long-term prophylactic therapy with antiarrhythmic drugs to maintain sinus rhythm (rhythm control) in patients with atrial fibrillation results in a better outcome than a strategy aimed at controlling heart rate and anticoagulation appropriate to the atrial fibrillation guidelines (rate control).2–6 In all five trials, there was no improvement in clinical outcome (stroke, death, heart failure, hospitalization) in patients comparing the two strategies. It is useful to focus on the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial since it is three-times the size ...

Clinical Factors That Influence Response to Treatment Strategies in Atrial Fibrillation: The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study

Clinical Factors That Influence Response to Treatment Strategies in Atrial Fibrillation: The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study

Factors Affecting Bleeding Risk During Anticoagulant Therapy in Patients With Atrial Fibrillation: Observations From the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study

Factors Affecting Bleeding Risk During Anticoagulant Therapy in Patients With Atrial Fibrillation: Observations From the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study

Clinical Factors That Influence Response to Treatment Strategies in Atrial Fibrillation. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study

Clinical Factors That Influence Response to Treatment Strategies in Atrial Fibrillation. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study

Factors Affecting Bleeding Risk During Anticoagulant Therapy in Patients With Atrial Fibrillation: Observations From the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study

Factors Affecting Bleeding Risk During Anticoagulant Therapy in Patients With Atrial Fibrillation: Observations From the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study

Influence of the Randomized Trials, AFFIRM and RACE, on the Management of Atrial Fibrillation in Two University Medical Centers

The results of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) and the Rate Control Versus Electrical Cardioversion for Persistent Atrial Fibrillation (RACE) study were presented in March 2002. These large studies showed no benefit of a rhythm-control strategy over a rate-control strategy in managing atrial fibrillation (AF). Cardioversion and atrioventricular junctional ablation are forms of rhythm control and rate control, respectively. The numbers of cardioversions and atrioventricular junctional ablations performed at the University of Virginia and the Medical College of Virginia during the 52 months before AFFIRM and RACE results were released and the 21 months afterward were compared. From January 1998 to March 2002, monthly averages of 31 +/- 8 elective cardioversions and 6 +/- 3 atrioventricular junctional ablations were performed; from April 2002 to December 2003, the monthly averages were 21 +/- 6 cardioversions (p = 0.001) and 9 +/- 3 ablations (p = 0.001). AF management changed at these institutions shortly after the RACE and AFFIRM results were released.