Rhythm-control Patients Research Articles

The RecordAF Study: Design, Baseline Data, and Profile of Patients According to Chosen Treatment Strategy for Atrial Fibrillation

The REgistry on Cardiac rhythm disORDers assessing the control of Atrial Fibrillation (RecordAF) is the first worldwide, 1-year observational, longitudinal study of the management of paroxysmal/persistent atrial fibrillation (AF) in recently diagnosed patients. The study was conducted at 532 sites in 21 countries across Europe, America, and Asia; recruitment was completed in April 2008. The primary objectives were to prospectively assess the therapeutic success and clinical outcomes in rhythm- and rate-control strategies. The study design and patient baseline data are reported. A total of 5,814 patients with AF were registered, and 5,604 were eligible for evaluation. Rhythm- and rate-control strategies were applied to 55% and 45% of patients, respectively, at study inclusion. Rhythm-control patients mainly received class III agents (45%) or beta blockers (51%), except for sotalol, and rate-control patients mainly received beta blockers (72%), except for sotalol, or cardiac glycosides (34%). Patients receiving a rhythm-control strategy were younger, had a lower resting heart rate, were more frequently symptomatic, and were more likely to have recently diagnosed AF or paroxysmal AF compared to patients receiving a rate-control strategy. A rate-control strategy was more common in patients with a history of heart failure or valvular heart disease and persistent AF. Rate-control patients more often had previous electrocardiographic evidence of AF and were not in sinus rhythm at inclusion (p <0.01 for both end points). Patients were followed at 6 and 12 months, and changes in therapeutic strategy and clinical outcomes were recorded. In conclusion, the RecordAF study results will provide a global perspective on current AF treatment strategies.

Atrial Fibrillation in Hypertrophic Obstructive Cardiomyopathy - Antiarrhythmics, Ablation and More!

Hypertrophic cardiomyopathy (HCM) is a genetic disease of the cardiac sarcomere with an autosomal dominant pattern of inheritance. Patients with HCM are at high risk of developing atrial fibrillation (AF) particularly in the setting of advanced diastolic dysfunction and left atrial enlargement. AF is a marker of increased mortality and morbidity and results in a significant reduction in quality of life. Antiarrhythmic medications improve symptoms and reduce AF recurrence, but few are safe and there exists little data to guide their long-term use in HCM. Non-pharmacologic approaches have emerged and have equal or greater efficacy than pharmacologic approaches. Although these approaches are promising, the long-term impact on atrial function needs to be carefully studied as it may impact quality of life in patients that age in the setting of a progressive diastolic disease disorder. Nonetheless, with the significant impact of AF in HCM, rhythm control strategies are often required. The understanding of rhythm control strategies in HCM, an often rapidly progressive diastolic dysfunction disorder, may provide insight in how to treat the much more prevalent AF patient with hypertensive cardiomyopathy. Regardless of treatment strategy (rhythm or rate control) patients are a moderate to high risk of thromboembolism and until data are available to suggest otherwise require long-term warfarin anticoagulation.

The Costs of Care in Atrial Fibrillation and the Effect of Treatment Modalities in Germany

Objective Atrial fibrillation (AF) is an increasing burden on health-care systems because of an aging population. This study aimed to estimate health-care resource use and costs of treating AF in Germany. Method A 6-month multicenter prospective observational cohort study with additional 3-month retrospective clinical data collection was performed in physician practices. AF-related resource use was documented by 3-month retrospective and 6-month prospective clinical data from physician charts and prospectively by patient questionnaires at 3 and 6 months. Cost calculation was from the health-care payer perspective. Results A total of 361 patients (mean age 71 ± 9 years, 61% male) were recruited from 45 physician practices. Of 311 (86.1%) patients with complete data, 75% had persistent AF; oral anticoagulation and/or aspirin were prescribed in 98%. A rhythm-control strategy was applied in 27%, rate control in 58%, and 15% received neither antiarrhythmic medication nor cardioversion. A higher proportion of rhythm-control patients had paroxysmal AF ( P < 0.001). Mean annual AF-related per-patient cost was 827 Euro ± 1476 (median 386 Euro). 50% of total costs were incurred by 11% of patients, driven by AF-related hospitalizations (44%). Antiarrhythmics and stroke prophylaxis accounted for 20% and 15% of expenditures, respectively. Mean annualized costs were higher for rhythm-control patients than for rate-control patients or those without antiarrhythmic treatment (1572 vs. 780 vs. 544 Euro, P < 0.001). Conclusion This evaluation provides an overview of current treatment modalities and cost of AF management in Germany. Efforts to reduce the economic burden of AF should focus on avoidance of AF hospital admissions and optimization of stroke prevention and rhythm control.

Rhythm vs. rate control of atrial fibrillation meta-analysed by number needed to treat.

Whenever feasible, rhythm control of atrial fibrillation (AF) was generally preferred over rate control, in the belief that it offered better symptomatic relief and quality of life, and eliminated the need for anticoagulation. However, recent trials appear to challenge these assumptions. To explore the desirability of rhythm vs. rate control of AF by systematic review of pertinent, published, randomized controlled trials (RCTs) and a meta-analysis by number needed to treat (NNT) year(-1), with respect to diverse clinically important outcomes. RCTs of outcome primarily comparing rate vs. rhythm control in patients with spontaneous AF were identified. For each outcome and assuming rhythm control to be the active treatment, relative risk reduction (RRR) and NNT year(-1) were derived for individual trials together with an NNT year(-1) for all trials combined; corresponding 95% confidence intervals (CI) were also calculated. Adverse drug reaction (ADR) and quality of life reporting were also assessed. In all, data from five suitable RCTs (entailing 5239 patients) were analysed. For hospitalization, available RRRs and NNT year(-1) values were all clinically and statistically significant. Overall, one additional patient was hospitalized for every 35 assigned to rhythm control (95% CI 27, 48). For the endpoints of death, 'ischaemic' stroke and 'non-CNS' bleeding, there was no significant difference. ADRs were significantly more common in rhythm control patients, whereas quality of life assessments revealed no difference. Thromboembolism was associated with cessation of or subtherapeutic anticoagulation, irrespective of treatment assignment. Reduced risk of hospitalization and non-inferiority for other endpoints all favour rate control, the less costly strategy. If symptoms of AF are not a problem, treatment should target optimizing rate control and more widespread and effective prophylactic anticoagulation.

Rate control versus rhythm control for patients with persistent atrial fibrillation with mild to moderate heart failure: Results from the RAte Control versus Electrical cardioversion (RACE) study

This study was conducted to compare rate- and rhythm-control therapy in patients with persistent atrial fibrillation (AF) and mild to moderate chronic heart failure (CHF). Rate control is not inferior to rhythm control in preventing mortality and morbidity in patients with AF. In CHF, this issue is still unsettled. In this predefined analysis of the RACE study, a total of 261 patients were in New York Heart Association (NYHA) classes II and III at baseline. These patients were analyzed. The primary end point was a composite of cardiovascular mortality, hospitalization for CHF, thromboembolic complications, bleeding, pacemaker implantation, and life-threatening drug side effects. Furthermore, quality of life was compared. After 2.3 +/- 0.6 years, the primary end point occurred in 29 (22.3%) of the 130 rate-control patients and in 32 (24.4%) of the 131 rhythm-control patients. More cardiovascular deaths, hospitalization for CHF, and bleeding occurred under rate control. Thromboembolic complications, drug side effects, and pacemaker implantation were more frequent under rhythm control. Quality of life did not differ between strategies. In patients successfully treated with rhythm control, the prevalence of end points was not different from those who were in AF at study end. However, the type of end point was different: mortality, bleeding, hospitalization for heart failure, and pacemaker implantation occurred less frequently. In patients with mild to moderate CHF, rate control is not inferior to rhythm control. However, if sinus rhythm can be maintained, outcome may be improved. A prospective randomized trial is necessary to confirm these results.

Are Transthoracic Echocardiographic Parameters Associated With Atrial Fibrillation Recurrence or Stroke?: Results From the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study

The purpose of this study was to evaluate the associations of transthoracic echocardiographic parameters with recurrent atrial fibrillation (AF) and/or stroke. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study, an evaluation of elderly patients with AF at risk for stroke, provided an opportunity to evaluate the implications of echocardiographic parameters in patients with AF. Transthoracic echocardiographic measures of mitral regurgitation (MR), left atrial (LA) diameter, and left ventricular (LV) function were evaluated in the AFFIRM rate- and rhythm-control patients who had sinus rhythm resume and had these data available. Risk for recurrent AF or stroke was evaluated with respect to transthoracic echocardiographic measures. Of 2,474 patients studied, 457 had > or =2(+)/4(+) MR, and 726 had a LA diameter >4.5 cm. The LV ejection fraction was abnormal in 543 patients. The cumulative probabilities of at least one AF recurrence/stroke were 46%/1% after 1 year and 84%/5% by the end of the trial (> 5 years), respectively. Multivariate analysis showed that randomization to the rhythm-control arm (hazard ratio [HR] = 0.64; p < 0.0001) and a qualifying episode of AF being the first known episode (HR = 0.70; p < 0.0001) were associated with decreased risk. Duration of qualifying AF episode >48 h (HR = 1.55; p < 0.0001) and LA diameter (p = 0.008) were associated with an increased risk of recurrent AF. Recurrent AF was more likely with larger LA diameters (HR = 1.21, 1.16, and 1.32 for mild, moderate, and severe enlargement, respectively). No transthoracic echocardiographic measures were associated with risk of stroke. In the AFFIRM study, large transthoracic echocardiographic LA diameters were associated with recurrent AF, but no measured echocardiographic parameter was associated with stroke.

Effect of rate or rhythm control on quality of life in persistent atrial fibrillation: Results from the Rate Control Versus Electrical Cardioversion (RACE) study

ObjectivesWe studied the influence of rate control or rhythm control in patients with persistent atrial fibrillation (AF) on quality of life (QoL). BackgroundAtrial fibrillation may cause symptoms like fatigue and dyspnea. This can impair QoL. Treatment of AF with either rate or rhythm control may influence QoL. MethodsQuality of life was assessed in patients included in the Rate Control Versus Electrical Cardioversion for Persistent Atrial Fibrillation (RACE) study (rate vs. rhythm control in persistent AF). Rate control patients (n = 175) were given negative chronotropic drugs and oral anticoagulation. Rhythm control patients (n = 177) received serial electrocardioversion, antiarrhythmic drugs, and oral anticoagulation, as needed. Quality of life was studied using the Short Form (SF)-36 health survey questionnaire at baseline, one year, and the end of the study (after 2 to 3 years of follow-up). At baseline, QoL was compared with that of healthy control subjects. Patient characteristics related to QoL changes were determined. ResultsMean follow-up was 2.3 years. At baseline, QoL was lower in patients than in age-matched healthy controls. At study end, under rate control, three subscales of the SF-36 improved. Under rhythm control, no significant changes occurred compared with baseline. At study end, QoL was comparable between both groups. The presence of complaints of AF at baseline, a short duration of AF, and the presence of sinus rhythm (SR) at the end of follow-up, rather than the assigned strategy, were associated with QoL improvement. ConclusionsQuality of life is impaired in patients with AF compared with healthy controls. Treatment strategy does not affect QoL. Patients with complaints related to AF, however, may benefit from rhythm control if SR can be maintained.