Rhythm Control Group Research Articles

Cognitive impairment, age, quality of life, and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study.

Atrial fibrillation (AF) treatment includes anticoagulation for high stroke risk individuals and either rate or rhythm control strategies. We aimed to investigate the impact of age, geriatric factors, and medical comorbidities on choice of rhythm versus rate control strategy in older adults. Patients with AF aged ≥65 years with CHA2 DS2 VASc score ≥2 and eligible for anticoagulation were recruited for the Systematic Assessment of Geriatric Elements-AF (SAGE-AF) prospective cohort study. An interview that included measures of HRQoL, cognitive function, vision, hearing, and frailty was performed. The association between these elements and AF treatment strategy was examined by multivariable logistic regression models. One thousand two hundred forty-four participants (mean age 76 years; 49% female; 85% non-Hispanic white) were enrolled. Rate and rhythm control were used in 534 and 710 participants, respectively. Compared to participants <75 years, those ≥75 were more likely to be treated with a rate control strategy (age 75-84 adjusted odds ratio [aOR] 1.37 [95% CI 0.99, 1.88]; age 85+ aOR=2.05, 95% CI 1.30, 3.21). Those treated with a rate control strategy were more likely to have cognitive impairment (aOR=1.50, 95% CI 1.13, 1.99), and peripheral vascular disease (PVD) (aOR=1.82, 95% CI 1.22, 2.72) but less likely to have visual impairment (aOR 0.73 [0.55, 0.98]), congestive heart failure (CHF; aOR 0.68 [0.49, 0.94]) or receive anticoagulation (aOR 0.53, 95% CI 0.36, 0.78). Older age, cognitive impairment, and PVD were associated with use of rate control strategy. Visual impairment, CHF, and anticoagulation use were associated with a rhythm control strategy. There was no difference in HRQoL between the rate and rhythm control groups. This study suggests that certain geriatric elements may be associated with AF treatment strategies. Further study is needed to evaluate how these decisions affect outcomes.

CE-543-03 EARLY RHYTHM CONTROL IN PATIENTS WITH INCIDENT ATRIAL FIBRILLATION WHO HAD A PRIOR HISTORY OF STROKE: A NATIONWIDE POPULATION-BASED COHORT STUDY

Early rhythm control therapy has been demonstrated to be associated with a lower risk of stroke compared to usual care in patients with atrial fibrillation (AF). However, there are limited data regarding the benefit of early rhythm control therapy for secondary prevention for stroke in patients with AF. To compare the risk of recurrent stroke between early rhythm control therapy and usual care in patients with new-onset AF and a history of prior stroke. Using the Korean nationwide claims database, we identified patients who were newly diagnosed as AF and had a history of prior stroke. Patients who received rhythm control therapy, including antiarrhythmic drug (AAD), direct current cardioversion (DCC), or AF catheter ablation, within 1 year after incident AF were defined as the early rhythm control group, otherwise as the usual care group. The propensity score weighting method was used to balance baseline characteristics between the two groups. Incident stroke was evaluated as a primary outcome. A total of 53,509 patients were included (mean age 72±11 years, 53% men; mean CHA2DS2-VASc score 5.5±1.6). All patients were prescribed oral anticoagulants. Among the total study population, 12,455 patients were assigned to the early rhythm control group (AAD, DCC, and AF catheter ablation in 99.4%, 8.6%, and 3.9%, respectively), and 41,054 patients were in the usual care group. During a median 2.6 years (IQR 1.5 to 4.5 years) of follow-up, 4382 patients had an incident stroke (IR, 2.6 per 100 person-years). Early rhythm control was associated with a lower risk of recurrent stroke compared to usual care (hazard ratio, 0.720, 95% confidence interval, 0.666-0.779, p<0.001) (Figure). Early rhythm control consistently showed a lower risk of stroke than usual care regardless of the characteristics of prior stroke, whether recent, severe, and disabling stroke or not. In this large-scale observational cohort study, early rhythm control within 1 year after AF diagnosis might be beneficial to prevent recurrent stroke in patients with incident AF and a history of prior stroke. Integrated care, including optimal rhythm control with appropriate anticoagulation, should be considered for patients who had incident AF and a history of stroke to reduce the risk of recurrent stroke.

Rhythm Control Better Prevents Dementia than Rate Control Strategies in Patients with Atrial Fibrillation-A Nationwide Cohort Study.

Background: Atrial fibrillation (AF) increases the risk of dementia. Whether the pharmacological rhythm control of AF can reduce the risk of dementia compared to the rate control strategy remains unclear. We hypothesize that the rhythm control strategy is better than the rate control strategy in preventing dementia. Methods: AF patients aged ≥65 years were identified from the Taiwan National Health Insurance Database. Patients receiving anti-arrhythmic drugs at a cumulative defined daily dose (cDDD) of >30 within the first year of enrollment constituted the rhythm control group. Patients who used rate control medications for a cDDD of >30 constituted the rate control group. A multivariate Cox hazards regression model was used to determine the hazard ratio (HR) for dementia. Results: A total of 3382 AF patients (698 in the rhythm control group; 2684 in the rate control group) were analyzed. During a 4.86 ± 3.38 year follow-up period, 414 dementia events occurred. The rhythm control group had a lower rate of dementia than the rate control group (adjust HR: 0.75, p = 0.031). The rhythm control strategy reduced the risk of dementia particularly in those receiving aspirin (p = 0.03). Conclusions: In patients with AF, pharmacological rhythm control was associated with a lower risk of dementia than rate control over a long-term follow-up period, particularly in patients receiving aspirin treatment.

Effects of Different Types of Meditation on Diastolic Blood Pressure

Background: The study was intended to find out the effects of different types of meditations namely transcendental meditation and heart rhythm meditation on diastolic blood pressure among male college students. Methodology: Sixty male students studying bachelor’s degree in colleges in and around Tiruvannamalai District, Tamil Nadu, India were randomly selected as subjects to achieve the purpose of this study. The age of subjects ranged between 18 and 24 years, height and weight ranged from 158 to 171 cm and 56 to 69 kg respectively. The selected sixty subjects were divided into three groups of twenty subjects each at random. Group I (transcendental meditation), Group II (heart rhythm meditation) and Group III (control). Prior to and immediately after the training programme, all the subjects of three groups were tested on the selected dependent variable. ANCOVA (analysis of covariance) was used to analyse the collected data to find out the effects of different types of meditations on diastolic blood pressure. Whenever the obtained ‘F’ ratio for the adjusted post-test mean was found to be significant, Scheffe’s test was applied as post hoc test to determine the paired mean differences, if any. The 0.05 level of confidence was fixed to test the level of significance which was considered as an appropriate. Results &amp; Conclusion: There was a significant differences exist among transcendental meditation group, heart rhythm meditation group and control group on selected physiological variable namely diastolic blood pressure. There was significant change on selected physiological variable namely diastolic blood pressure due to transcendental meditation and heart rhythm meditation after twelve weeks of training period. Significant differences were found between transcendental meditation group and heart rhythm meditation group on selected physiological variable namely diastolic blood pressure after twelve weeks of training period.

Randomized Ablation-Based Rhythm-Control Versus Rate-Control Trial in Patients With Heart Failure and Atrial Fibrillation: Results from the RAFT-AF trial.

Atrial fibrillation (AF) and heart failure (HF) frequently coexist and can be challenging to treat. Pharmacologically based rhythm control of AF has not proven to be superior to rate control. Ablation-based rhythm control was compared with rate control to evaluate if clinical outcomes in patients with HF and AF could be improved. This was a multicenter, open-label trial with blinded outcome evaluation using a central adjudication committee. Patients with high-burden paroxysmal (>4 episodes in 6 months) or persistent (duration <3 years) AF, New York Heart Association class II to III HF, and elevated NT-proBNP (N-terminal pro brain natriuretic peptide) were randomly assigned to ablation-based rhythm control or rate control. The primary outcome was a composite of all-cause mortality and all HF events, with a minimum follow-up of 2 years. Secondary outcomes included left ventricular ejection fraction, 6-minute walk test, and NT-proBNP. Quality of life was measured using the Minnesota Living With Heart Failure Questionnaire and the AF Effect on Quality of Life. The primary analysis was time-to-event using Cox proportional hazards modeling. The trial was stopped early because of a determination of apparent futility by the Data Safety Monitoring Committee. From December 1, 2011, to January 20, 2018, 411 patients were randomly assigned to ablation-based rhythm control (n=214) or rate control (n=197). The primary outcome occurred in 50 (23.4%) patients in the ablation-based rhythm-control group and 64 (32.5%) patients in the rate-control group (hazard ratio, 0.71 [95% CI, 0.49-1.03]; P=0.066). Left ventricular ejection fraction increased in the ablation-based group (10.1±1.2% versus 3.8±1.2%, P=0.017), 6-minute walk distance improved (44.9±9.1 m versus 27.5±9.7 m, P=0.025), and NT-proBNP demonstrated a decrease (mean change -77.1% versus -39.2%, P<0.0001). Minnesota Living With Heart Failure Questionnaire demonstrated greater improvement in the ablation-based rhythm-control group (least-squares mean difference of -5.4 [95% CI, -10.5 to -0.3]; P=0.0036), as did the AF Effect on Quality of Life score (least-squares mean difference of 6.2 [95% CI, 1.7-10.7]; P=0.0005). Serious adverse events were observed in 50% of patients in both treatment groups. In patients with high-burden AF and HF, there was no statistical difference in all-cause mortality or HF events with ablation-based rhythm control versus rate control; however, there was a nonsignificant trend for improved outcomes with ablation-based rhythm control over rate control. URL: https://www. gov; Unique identifier: NCT01420393.

Rhythm control versus rate control in patients with atrial fibrillation and heart failure across the left ventricular ejection fraction spectrum

BackgroundRhythm control and rate control are both employed commonly in patients with atrial fibrillation (AF) and heart failure (HF), but limited real-world data exist on them. We aimed to compare outcomes between these two strategies across the left ventricular ejection fraction (LVEF) spectrum. Materials and methodsThis retrospective cohort study used data from the randomized MISOAC-AF trial, including from patients with AF and coexistent HF who were hospitalized and followed up after discharge. At baseline, the patients were classified into pharmaceutical (or electrical cardioversion) rhythm control strategy or rate control treatment (b-blocker, digoxin, calcium channel blockers) groups. The primary outcome was all-cause mortality. Kaplan-Meier curves and multivariable-adjusted Cox regression were utilized to compare the two strategies. Spline curve models were used to demonstrate the results across the LVEF stratified spectrum. ResultsIn total, 199 AF patients with HF were studied (mean age, 77 years). At discharge, 73 (36.7%) patients received rhythm control and 126 (63.3%) rate control treatment. After a median follow-up period of 31 months, 26 (35.6%) patients in the rhythm-control group died, as compared to 43 (33.3%) in the rate-control group (aHR: 1.29; 95% CI: 0.78-2.14; p = 0.31). The spline curves also revealed no difference in all-cause mortality favoring either strategy in any HF subtype across the nominally classified LVEF. ConclusionThe use of a pharmacological rhythm-control strategy was not associated with a survival advantage compared to the rate control strategy in recently hospitalized patients with AF and comorbid HF. More randomized trials and large studies are needed in the future to explore these results in each subgroup of HF patients.

Rhythm Control Vs Rate Control in a Contemporary Ambulatory Atrial Fibrillation Cohort: Post Hoc Analysis of the IMPACT-AF Trial

BackgroundWe examined the characteristics and outcomes in a contemporary ambulatory population of patients with atrial fibrillation (AF), comparing rate control with rhythm control. MethodsThis is a post hoc analysis of a cluster-randomized trial (Integrated Management Program Advancing Community Treatment of Atrial Fibrillation [IMPACT-AF]) in ambulatory AF patients from 2016 to 2018, which compared use of a clinical decision support tool for general practitioners to usual care. This analysis compared patients managed with rate vs rhythm control, at entry into the study. Outcomes included AF-related emergency department (ED) visits, unplanned cardiovascular hospitalizations, and bleeding events at 12 months. ResultsA total of 870 patients were included in this analysis, 99 (11.4%) in the rhythm-control group, and 40% women. In the rhythm-control group, the mean age was younger (70 ± 11.4 vs 72.7 ± 9.5 years, P = 0.03), a higher number were paroxysmal (80% vs 43%, P < 0.001), and CHADS2 scores were lower. The rate of AF-related ED visits was higher in the rhythm-control group (17.2 vs 7.3%, P = 0.003), and repeat visits (rate ratio 3.03, 95% confidence interval [1.99-4.52], P < 0.001). The number of repeat ED visits was independently associated with female sex and being in the rhythm-control group. ConclusionsBoth rate- and rhythm-control patients have recurrent ED visits, with a higher rate in patients treated with rhythm control. These findings are observational, but taken in the context of current guidelines could help develop further therapies aimed at improving symptom burden in both rhythm- and rate-control patients to broadly improve healthcare utilization in the AF population.

Risks and Benefits of Early Rhythm Control in Patients With Acute Strokes and Atrial Fibrillation: A Multicenter, Prospective, Randomized Study (the RAFAS Trial).

BackgroundThe purpose of the RAFAS (Risk and Benefits of Urgent Rhythm Control of Atrial Fibrillation in Patients With Acute Stroke) trial was to explore the risks and benefits of early rhythm control in patients with newly documented atrial fibrillation (AF) during an acute ischemic stroke (IS).Method and ResultsAn open‐label, randomized, multicenter trial design was used. If AF was diagnosed, the patients in the early rhythm control group started rhythm control within 2 months after the occurrence of an IS, unlikely the usual care. The primary end points were recurrent IS within 3 and 12 months. The secondary end points were a composite of all deaths, unplanned hospitalizations from any cause, and adverse arrhythmia events. Patients (n=300) with AF and an acute IS (63.0% men, aged 69.6±8.5 years; 51.2% with paroxysmal AF) were randomized 2:1 to early rhythm control (n=194) or usual care (n=106). A total of 273 patients excluding those lost to follow‐up (n=27) were analyzed. The IS recurrences did not differ between the groups within 3 months of the index stroke (2 [1.1%] versus 4 [4.2%]; hazard ratio [HR], 0.257 [log‐rank P=0.091]) but were significantly lower in the early rhythm control group at 12 months (3 [1.7%] versus 6 [6.3%]; HR, 0.251 [log‐rank P=0.034]). Although the rates of overall mortality, any cause of hospitalizations (25 [14.0%] versus 16 [16.8%]; HR, 0.808 [log‐rank P=0.504]), and arrhythmia‐related adverse events (5 [2.8%] versus 1 [1.1%]; HR, 2.565 [log‐rank P=0.372]) did not differ, the proportion of sustained AF was lower in the early rhythm control group than the usual care group (60 [34.1%] versus 59 [62.8%], P<0.001) in 12 months.ConclusionsThe early rhythm control strategy of an acute IS decreased the sustained AF and recurrent IS within 12 months without an increase in the composite adverse outcomes.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT 02285387.

Early rhythm-control therapy in patients with atrial fibrillation: a nationwide cohort study

Abstract Background In the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4), early rhythm control was associated with better clinical outcomes for patients with atrial fibrillation (AF). However, the intervention arm had more structured and regular followup, and whether the better outcomes of patients assigned to rhythm control were solely due to “early” intervention or because of more regular and structured follow up was unclear. Purpose We aimed to investigate whether the findings of the EAST trial are applicable to the “real world” clinical setting, where a less structured management protocol is operated. Methods From 2001 to 2016, 301,064 newly-diagnosed AF patients were identified from Taiwan National Health Insurance Research Database. Among these patients, 62,649 AF patients receiving antiarrhythmic drugs or catheter ablation within 1 year after AF being diagnosed (similar to the timing definition of the EAST-AFNET 4 trial) were categorized as the early rhythm control group, and the remaining 238,415 patients were defined as usual care group. Risk of clinical events were compared between 2 groups. Results Compared to usual care, early rhythm control was associated with a lower adjusted risk of ischemic stroke (aHR 0.771, 95CI 0.751–0.792; p&amp;lt;0.001), heart failure (aHR 0.851, 95% CI 0.806–0.891; p&amp;lt;0.001), acute myocardial infarction (aHR 0.915, 95% CI 0.877–0.955; p&amp;lt;0.001), mortality (aHR 0.794, 95% CI 0.782–0.806; p&amp;lt;0.001) and composite adverse events (aHR 0.823, 95% CI 0.813–0.834; p&amp;lt;0.001) (Figure). Compared to usual care, the lower risks of ischemic stroke (aHR 0.746, 95% CI 0.717–0.775), heart failure (aHR 0.819, 95% CI 0.798–0.841), mortality (aHR 0.777, 95% CI 0.759–0.795) and composite adverse events (aHR 0.802, 95% CI 0.787–0.818) associated with early rhythm control were even more evident when performed early (&amp;lt;3 months) than later periods (3–6 months, 7–9 months and 10–12 months; pint &amp;lt;0.001). Principal results were generally consistent for majority of subgroups studied and among the cohort after the propensity matching. Conclusions In this nationwide cohort study, early rhythm control therapy was associated with a lower risk of adverse events than usual care among patients with early AF. Outcomes were even better with earlier (&amp;lt;3 months) intervention. Funding Acknowledgement Type of funding sources: None.

Serum Beta-2 Microglobulin: A Possible Biomarker for Atrial Fibrillation.

BackgroundAtrial fibrillation (AF) is the most common persistent arrhythmia that can cause complications (including stroke). Therefore, its diagnosis and treatment require increased attention. Although beta-2 microglobulin (β2-MG) is a novel marker of cardiovascular disease, its role in AF has not been evaluated.Material/MethodsWe conducted a case-control study with 61 patients who had normal heart rhythm (control group) and 60 patients with AF (research group). We analyzed the serum β2-MG levels in both groups and performed multivariate analysis to assess the correlation between β2-MG and left atrial remodeling. In addition, β2-MG levels were compared between the left atrial blood and peripheral venous blood of another set of 57 patients with AF, who underwent cryoballoon ablation.ResultsThere were no statistically significant differences in the baseline characteristics (age, sex, history of hypertension, diabetes mellitus, previous stroke, coronary heart disease, and estimated glomerular filtration rate) of the control and research groups. The left atrial anteroposterior diameters (LAD) and left ventricular end-systolic diameters in the AF group were significantly larger compared to the control group (P<0.01). Serum β2-MG levels in patients with AF were significantly higher (P<0.01) and positively correlated with the LAD (B-coefficient 25.482, 95% CI 14.410~36.554, P<0.01), serum β2-MG levels in the left atrial blood were significantly higher than those in peripheral venous blood (P<0.01), and serum β2-MG levels were an independent predictor of AF.ConclusionsWith the development of atrial fibrillation, the serum β2-MG levels increase and are closely related to the left atrial remodeling due to AF. Therefore, β2-MG can be an effective biomarker for predicting AF.

Rate Versus Rhythm Control in Heart Failure Patients with Post-Operative Atrial Fibrillation After Cardiac Surgery

BackgroundWhether rhythm control for post-operative atrial fibrillation after cardiac surgery (POAF) is superior to rate control in patients with heart failure or systolic dysfunction (HF) is not known. MethodsWe performed a post-hoc analysis of a trial by the Cardiothoracic Surgical Trials Network, which randomized patients with POAF after cardiac surgery to rate control or rhythm control with amiodarone/cardioversion. We assessed subgroups of trial participants defined by heart failure/cardiomyopathy history or left ventricular ejection fraction (LVEF) < 50%. We conducted a stratified analysis in patients with and without HF to explore outcomes of rhythm versus rate control strategy. ResultsOf 523 subjects with POAF after cardiac surgery, 131 (25%) had HF. 49% of HF patients were randomized to rhythm control. In HF patients, rhythm control was associated with less atrial fibrillation within the first 7 days. There were no differences in rhythm at 30- and 60-day follow-up. In the HF group, there were significantly more subjects with AF < 48 hours in the rhythm control group compared to rate control group- 68.8% compared to 46.3%, P=0.009. By comparison, in the non-HF stratum, 54.4% of the rate control group had AF < 48 hours compared to 63.5% of the rhythm control group (P=0.067).), though there was no significant interaction of heart failure with cardiac rhythm at 7 days (Pinteraction 0.16). ConclusionRhythm control for HF patients with POAF after cardiac surgery increases early restoration of sinus rhythm. Rate and rhythm control are both reasonable for HF patients with AF after cardiac surgery

Rhythm or rate control strategy in CRT recipients with long-standing persistent atrial fibrillation - preliminary results of the PilotCRAfT study

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): National Institute of Cardiology in Warsaw Statutory Grant Background The presence of atrial fibrillation (AF) in cardiac resynchronization therapy (CRT) recipients is common and AF is a marker of poorer CRT response. The negative influence of AF on CRT efficacy is mediated mainly by the drop of the effectively captured biventricular paced beats percentage (BiVp%) which should exceed 95-98% to warrant good CRT response. Sinus rhythm (SR) restoration may improve CRT efficacy which in turn may protect AF recurrence. However, there is lack of randomized studies comparing rhythm and rate control strategies in these patients. Purpose The purpose of the Pilot-CRAfT study (NCT01850277) was to compare the efficacy of rhythm vs rate control strategy in CRT patients with long-standing persistent or permanent atrial fibrillation. Methods The study included patients with CRT and permanent or persistent AF lasting for ≥6 months, resulting in BiVp% &amp;lt;95%, who were randomly assigned to rhythm or rate control strategy. The rhythm control strategy comprised of external electrical cardioversion (EEC). The rate control strategy included pharmacotherapy and atrioventricular node ablation (AVNA) as needed. Both of the study arms received amiodarone. The follow-up lasted 12 months. The primary endpoint was the 12-month BiVp%. The patients underwent ECHO, cardiopulmonary test, quality of live (QoL) and clinical outcomes assessment. Results The study included 43 CRT patients (97,7% males) aged 68,4 (SD: ±8,3) years with mean BiVp% 82,4% ±9,7% at baseline. The mean duration of AF paroxysm was 25 ±19 months. The mean baseline left ventricular ejection fraction (LVEF), left atrium area and maximal oxygen uptake (VO2max) were: 30 ±8%, 33 ±7 cm2, 14 ±5 mL/(kg*min), respectively. The EEC was performed in 19 out of 22 patients assigned to the rhythm control arm. The immediate success rate of EEC was 58%. 42% of the rhythm control arm patients remained in SR after 12 months. In the rate control group 1 person underwent AVNA and in 1 patient spontaneous SR resumption was observed. After 12 months there was significant BiVp% increase in both the rhythm and the rate control arms (98,1 ±2,3 vs 96,3 ±3,9%, respectively. The BiVp% differences between the groups were not significant (P = 0,093). However, in the per protocol analysis, the rhythm control group had greater LVEF after 12 months as opposed to the rate control arm (36,8% vs 29,9% respectively, P = 0,039). The LVEF raised significantly in the rhythm control group (ΔLVEF 5,0 (95%CI: 1,54; 8,46)). No significant differences between the groups in the VO2max, QoL, clinical and safety end-points were noticed. Conclusions Structured follow-up of CRT patients with long-standing persistent or permanent AF leads to significant BiVp% increase exceeding 95%. The rate control strategy did not improve CRT effectivness, irrespective of high BiVp%. However limited in the efficacy, the rhythm control strategy may improve CRT outcome in these patients, resulting in LVEF increase.

Epicardial fat and the risk of atrial tachy-arrhythmia recurrence post pulmonary vein isolation: a computed tomography study.

Epicardial and Pericardia fat have been hypothesized to exert local and systemic pathogenic effects on nearby cardiac structures. The present study aimed to evaluate the impact of epicardial and pericardial fat volumes on the outcome of patients that underwent a first pulmonary vein isolation (PVI) with cryoablation. We included 130 consecutive patients with atrial fibrillation (AF) that underwent contrast enhanced ECG-gated cardiac computed tomography (CCT) before a PVI. The control group included 50 patients in normal sinus rhythm that underwent ECG-gated CT to rule out coronary artery disease. Epicardial and pericardial fat volumes were quantified with CCT. Patients with AF compared to patients with normal sinus rhythm (control group) had significantly larger epicardial (140.3 ± 58.1 vs. 55.9 ± 17.7ml; respectively, P < 0.001) and pericardial (77.0 ± 35.5ml vs. 27.2 ± 9.5ml; respectively, P < 0.001) fat volumes. Among patients that underwent PVIs, those with AF recurrence had a greater epicardial (175.0 ± 54.4ml vs. 130.7 ± SD 54.2ml; respectively, P < 0.001) and pericardial (93.7 ± SD 42.8 vs. 72.5 ± SD 31.9ml; respectively, P < 0.001) fat volumes, compared to patients with no AF recurrence. Multivariate analyses revealed that epicardial fat was an independent predictor of recurrence post-ablation (HR = 1.08, 95% CI 1.02-1.16 per 10-ml increase in volume; P = 0.009). Pericardial fat was associated with 7% increase in risk of recurrent AF (HR = 1.07, 95% CI 0.98-1.18; P = 0.117). Epicardial fat, assessed with contrast enhanced CCT, is an independent predictor of AF recurrence after PVI ablation.

Rhythm-control therapy for new-onset atrial fibrillation in critically ill patients: A post hoc analysis from the prospective multicenter observational AFTER-ICU study.

Sustained new-onset atrial fibrillation (AF) in the intensive care unit has been reported to be associated with poor outcomes. However, in critical illness, whether rhythm-control therapy can achieve sinus rhythm (SR) restoration is unknown. This study aimed to assess the impact of rhythm-control therapy on SR restoration for new-onset AF in critically ill patients. This post-hoc analysis of a prospective multicenter observational study involving 32 Japan intensive care units compared patients with and without rhythm-control therapy for new-onset atrial fibrillation (AF) and conducted a multivariable analysis using Cox proportional hazards regression analysis including rhythm-control therapy as a time-varying covariate for SR restoration. Of 423 new-onset AF patients, 178 patients (42%) underwent rhythm-control therapy. Among those patients, 131 (31%) underwent rhythm-control therapy within 6h after AF onset. Magnesium sulphate was the most frequently used rhythm-control drug. The Cox proportional hazards model for SR restoration showed that rhythm-control therapy had a significant positive association with SR restoration (adjusted hazard ratio: 1.46; 95% confidence interval: 1.16-1.85). However, the rhythm-control group had numerically higher hospital mortality than the non-rhythm-control group (31% vs. 23%, p=0.09). Rhythm-control therapy for new-onset AF in critically ill patients was associated with SR restoration. However, patients with rhythm-control therapy had poorer prognosis, possibly due to selection bias. These findings may provide important insight for the design and feasibility of interventional studies assessing rhythm-control therapy in new-onset AF.

A randomized ablation-based atrial fibrillation rhythm control versus rate control trial in patients with heart failure and high burden atrial fibrillation: The RAFT-AF trial rationale and design

Heart failure (HF) and atrial fibrillation (AF) are 2 cardiac conditions that are increasing in prevalence and incidence. The 2 conditions frequently coexist, and are associated with increased morbidity and mortality. Catheter ablation of AF has been successfully performed in patients with HF, with an improvement in HF and AF, when compared to amiodarone, but further data is required to compare this to rate control. ObjectivesThe primary objective is to determine whether AF treated by catheter ablation, with or without antiarrhythmic drugs reduces all-cause mortality and hospitalizations for HF as compared with rate control in patients with HF and a high burden AF. MethodsThis is a multi-center prospective randomized open blinded endpoint (PROBE) study. Patients with NYHA class II-III HF (HF with reduced ejection fraction (<35%) or HF with preserved ejection fraction), and high burden AF are included in the trial. Patients are randomized to either rate control or catheter ablation-based AF rhythm control in a 1:1 ratio. Patients in the rate control group receive optimal HF therapy and rate control measures to achieve a resting hazard ratio (HR) < 80 bpm and 6-minute walk HR < 110 bpm. Patients randomized to catheter ablation-based AF rhythm control group receive optimal HF therapy and one or more aggressive catheter ablation, which include PV antral ablation and LA substrate ablation with or without adjunctive antiarrhythmic drug. The primary outcome is a composite of all-cause mortality and hospitalization for heart failure defined as an admission to a health care facility. The sample size is 600. Enrolment has been completed.

Differences in Atrial Fibrillation Symptoms and Quality of Life and Response to Therapy Across Race-Ethnicity

Objectives: To determine whether race-ethnicity modulates severity of atrial fibrillation (AF) symptoms, quality-of-life (QoL) and response to therapy. Background: Although the severity of AF symptoms is highly variable when selecting a rate or rhythm control approach, it remains unclear if race-ethnicity influences AF symptoms and QoL. Methods: We prospectively enrolled 453 patients with new-onset AF in a clinical-genetic registry. Baseline assessment of patients before treatment initiation included detailed patient history and administration of the Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) questionnaire in African-Americans, European-Americans, and Hispanics/Latinos. We assessed AFEQT scores at baseline and average of 8 months after starting treatment on maximal doses. Results: Of 415 consecutive patients with AF, 181 (43.6%) were African-American, 139 (33.5%) European-American and 95 (22.9%) Hispanic/Latino with a mean age of 62.0{plus minus}13.1 years. Two-hundred fifteen (51.8%) were treated with rate control versus 200 (48.2%) with rhythm control. Both African-American (53.0%) and Hispanic/Latino (65.3%) patients were more likely to be initiated rate control as compared with European-Americans (41%; P=0.0002) despite lower baseline AFEQT scores (African-American: 73.6{plus minus}23.0; Hispanic/Latino: 74.8{plus minus}21.2; and European-American: 76.9{plus minus}20.6; P=0.05) and poorer QoL. In the rhythm control group, the AFEQT scores and QoL improved in African-Americans (ΔScore: 9.5{plus minus}26.0; P<0.001) and European-Americans (ΔScore: 9.7{plus minus}19.6; P<0.0001) and was associated with improvement in symptoms and activities of daily living. Multivariate predictors of improvement in QoL included rhythm therapy, obesity, coronary artery disease, and private health insurance. Conclusions: Our findings may have important clinical implications for the assessment of symptoms and management of AF in African-Americans and Hispanics/Latinos.

Rate Control Versus Rhythm Control in Patients with Left Ventricular Assist Devices and Atrial Fibrillation.

Atrial fibrillation (AF) is a common comorbidity in patients with left ventricular assist devices (LVAD) with no defined guideline treatment strategy of rate versus rhythm control. The purpose of this study is to determine the effects of rate versus rhythm control for AF on the outcomes of patients with LVAD at our institution. Consecutive patients who underwent LVAD implantation at St Vincent Hospital from January 1, 2015 to December 31, 2017 were retrospectively evaluated. Patients with AF were identified and divided into rate control or rhythm control groups. The primary outcome evaluated was a composite of death, heart failure admission, gastrointestinal bleed, ventricular tachycardia, cerebrovascular accident, hemolysis, and pump thrombosis. Secondary outcomes included the individual variables from the primary outcome. Out of 201 patients that underwent LVAD implantation, 81 had AF after implantation and were included with a median follow-up period of 384 days. The rate control group (n = 31; 38%) and the rhythm control group (n = 51; 62%) had no difference in composite outcomes (61% vs 59%, p = 0.83). When taken individually there was no difference in outcomes between the two groups. Thirteen patients underwent electrical cardioversion and successful conversion to normal sinus rhythm occurred in 71% of cases with a 60% recurrence rate. There was no difference in primary outcome between rate and rhythm control groups. These data suggest that maintenance of sinus rhythm may not be necessary in all patients with LVAD.

Associated analysis of PER1/TUBB2B with endometrial cancer development caused by circadian rhythm disorders.

Endometrial cancer (EC) is one of the most common gynecologic malignancies, and the incidence rate of night shift among women workers is higher than that in the general population. Circadian rhythm disorder, mainly rhythm gene, is related to various tumor onset, including EC. This study described the sleep/night-shift features of EC patients, explored the mechanism of the circadian clock gene PER and investigated prognostic and functional values of Per1 caused by night shift. A total of 619 subjects were enrolled and divided into two groups according to night-shift duties (rhythm group and control group), analyzed for clinical risk factors and night shift features of endometrial carcinoma. Then samples were randomly selected for sequencing and western blot were performed, and the function of overexpressed PER1 in ishikawa cells was explored. We noticed that severer EC patients experienced night-shift more frequently and with longer durations. A total of 58,174 differentially expressed genes were discovered, mainly rhythm genes and related to up and downstream regulatory genes. Western blot showed that the rhythm group had elevated protein expression of BCAS4, TUBB2B and RSPO4, and decreased expression of PER1 and PER2 in night-shift. In TCGA-EC datasets, PER1 was decreased in the EC patients with a significantly positive correlation with PER2, and higher PER1 expression indicated longer survival, opposite to TUBB2B. The research of overexpressing PER1 gene in EC ishikawa cells found that PER1 can promote apoptosis, expression of TNF-a, IL-6 and PD-1/PD-L1, inhibit the tumor invasion and expression of TUBB2B gene. Together, EC severity was associated with night-shift and rhythm disorders. The rhythm relating factors PER1, TUBB2B and tumor immune factors may regulate the mechanisms of EC onset and progression.

Pharmacological rhythm versus rate control in patients with atrial fibrillation and heart failure: the CASTLE-AF trial.

The value of antiarrhythmics to maintain normal sinus rhythm in patients with atrial fibrillation (AF) and heart failure (HF) is still being debated. We aimed to determine whether rhythm control using antiarrhythmic drugs (AADs) is more effective than rate control in improving outcomes in this population. In this sub-analysis of the CASTLE-AF study, we included patients that were treated pharmacologically either to maintain sinus rhythm or to achieve rate control. The primary endpoint was defined as a composite of death from any cause or worsening of HF that led to an unplanned overnight hospitalization. Among 210 patients (mean age of 64.1 ± 10.8years, 83.3% male) treated pharmacologically, 60 patients were in the rhythm control group and 150 were in the rate control group. Patients in the rhythm control group were less likely to be assigned a beta-blocker (53 (88.3%) vs 141 (97.9%), P = 0.004) and digitalis (8 (13.3%) vs 53 (36.8%), P < 0.001). Over a median follow-up of 3.76 (95% confidence interval (CI), 3.23, 4.48) years, the primary composite endpoint of all-cause mortality and HF admissions occurred in 23 patients (38.3%) in the rhythm control arm vs 67 (44.7%) in the rate control arm (hazard ratio, 0.99; 95% CI, 0.62 to 1.60; P = 0.976). In CASTLE-AF among AF patients with HF, rhythm control with AADs did not significantly reduce the primary composite endpoint of all-cause mortality and HF hospitalization when compared with a pharmacological rate control strategy.

Rhythm versus rate control strategies regarding anticoagulant use in elderly non-valvular atrial fibrillation patients: Subanalysis of the ANAFIE (All Nippon AF In the Elderly) Registry

BackgroundData on real-world antiarrhythmic and anticoagulant therapy use in elderly atrial fibrillation (AF) patients are lacking; thus, we performed a subanalysis of data from the ANAFIE registry to clarify the current management of Japanese patients aged ≥75 years with non-valvular AF. MethodsThe ANAFIE registry was a multicenter, prospective, observational study. Patients were stratified into three groups: rhythm control group, rate control group, and no antiarrhythmic group. The CHADS2, CHA2DS2-VASc, and HAS-BLED scores were used to estimate embolic and bleeding risk. ResultsAmong 32,490 patients, the overall frequencies of AF by type were 42.0 % (paroxysmal), 30.1 % (persistent and long-standing persistent), and 27.9 % (permanent). Significant differences (p < 0.0001, each) in age were observed among the three groups; more patients aged 75–79 years received rhythm control (44.2 %) vs rate control (38.8 %). Patients aged ≥85 years received either rate control therapy or no antiarrhythmic agent (∼20 %, each). In the overall population, 36.9 % and 19.6 % of patients were receiving rate and rhythm control therapy, respectively; 43.4 % were not receiving antiarrhythmic therapy. The rate control group consisted mainly of patients with persistent (16.3 %) and permanent AF (38.6 %), and the rhythm control group, of patients with paroxysmal AF (79.0 %). Significantly lower embolic and bleeding risk scores and significantly higher embolic risk scores were observed in patients in the rhythm and rate control groups, respectively. In total, 92.1 % of elderly Japanese patients with AF were receiving anticoagulant therapy. The frequency of direct-acting oral anticoagulant (DOAC) use was similar (∼66 %) among the three groups. Significantly more patients in the rate control group (28.6 %) were being treated with warfarin than in the rhythm control group (21.6 %) (p < 0.0001). ConclusionsUse versus non-use and antiarrhythmic therapy varied significantly by age, stroke risk scores, type of AF, and DOAC use between subgroups.