Is rate control better than rhythm control for atrial fibrillation in older high-risk patients?

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Q&A

Is rate control better than rhythm control for atrial fibrillation in older high-risk patients?

J Fam Pract. 2003 March;52(3):183-200

By

Joseph J. Saseen, PharmD

BACKGROUND: The goal for managing high-risk patients who have atrial fibrillation traditionally has been to achieve and maintain normal sinus rhythm. This approach often requires multiple episodes of cardioversion and the chronic use of potentially toxic anti-arrhythmic drugs. However, rate control with chronic anticoagulation therapy is a potentially safer and more commonly used approach.
POPULATION STUDIED: This multicenter study included 4060 patients with atrial fibrillation, who were over the age of 65 years and had other risk factors for stroke or death (not described, but determined based on the judgment of the clinical investigators). At baseline, 50.8% had hypertension, 26.1% had coronary artery disease, and 23.1% had a history of heart failure.
STUDY DESIGN AND VALIDITY: In this unblinded study, patients were randomized to receive either rhythm control or rate control therapy and were followed for a mean of 3.5 years. Concealment of allocation to treatment group was not discussed. In the rhythm control group, the treating physician chose the anti-arrhythmic drug. Cardioversion and combination therapy were allowed if necessary. Amiodarone was used most frequently (62.8% used at any time) followed by sotalol (41.1%), propafenone (14.5%), and others.
OUTCOMES MEASURED: Overall mortality was the primary endpoint. A composite of death, disabling stroke, disabling anoxic encephalopathy, major bleeding, and cardiac arrest was the secondary endpoint. Hospitalizations and adverse drug events were other outcomes measured.
RESULTS: There was no statistical difference in mortality (26.7 and 25.9 %, rhythm and rate control groups, respectively; P=.08) or in the composite secondary endpoint mortality (32.0 and 32.7%, rhythm and rate control groups, respectively; P=.33). Hospitalizations were more frequent in the rhythm-control group as compared with the rate-control group (80.1% vs 73.0%; P<.001). Adverse drug effects such as pulmonary events, gastrointestinal events, bradycardia, prolonged corrected QT interval, and Torsade de pointes were all statistically higher in the rhythm-control group (P<.07 for all). Continuous warfarin therapy was frequently used in both groups (85% and approximately 70%, rate and rhythm control groups, respectively).

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Is rate control better than rhythm control for atrial fibrillation in older high-risk patients?

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