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Rhythm control not superior to rate control in clinical outcomes for AF
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For patients with atrial fibrillation in the ORBIT-AF registry, rhythm control was not superior to rate control in clinical outcomes, but was associated with greater CV hospitalizations, according to new findings.
Randomized clinical trials had not determined a difference in clinical outcomes between patients with AF on rhythm control vs. rate control, but little evidence exists comparing the strategies in real-world practice, according to the study background.
Amit Noheria, MBBS, SM, from Washington University, St. Louis, and colleagues analyzed 6,988 patients from the ORBIT-AF registry (median age, 74 years; 56% men). Patients were stratified by treatment strategy — rhythm control or rate control — and assessed for the following outcomes: all-cause mortality; CV mortality; first CV hospitalization; CV hospitalization or death; first stroke, systemic embolism or transient ischemic attack; death, stroke, systemic embolism or TIA; new-onset HF; and first major bleeding. Median follow-up was 2.3 years.
In an unadjusted analysis, compared with rate control, rhythm control was associated with lower all-cause mortality (HR = 0.65; 95% CI, 0.55-0.77), CV death (HR = 0.69; 95% CI, 0.52-0.93), first stroke/systemic embolism/TIA (HR = 0.73; 95% CI, 0.56-0.97), death/first stroke/systemic embolism/TIA (HR = 0.69; 95% CI, 0.6-0.8) and major bleeding (HR = 0.78; 95% CI, 0.66-0.92), but more frequent CV hospitalizations (HR = 1.22; 95% CI, 1.09-1.37), according to the researchers.
However, after they made adjustments after inverse propensity weighing, the differences between the groups in clinical outcomes were no longer statistically significant, except for rhythm control being associated with more CV hospitalizations (HR = 1.24; 95% CI, 1.1-1.39) and CV hospitalization or death (HR = 1.16; 95% CI, 1.05-1.29) than rate control.
“Rhythm control patients experience more [CV] hospitalizations, possibly related to elective hospitalizations for changes in antiarrhythmic drug regimen or procedures (eg, cardioversion, catheter ablation),” the researchers wrote. “Therefore, these findings support current guideline recommendations that the primary indication for rhythm control therapy is for the reduction of symptoms and improvement in quality of life.”
In a related editorial, D. George Wyse, MD, PhD, FACC, emeritus professor in the department of cardiac sciences at the Libin Cardiovascular Institute of Alberta, University of Calgary, wrote that one interpretation of the results is that “so far, catheter-based and surgical procedures to restore and maintain sinus rhythm have made little impact on the ‘no difference’ paradigm compared to rate control in the general population with AF.” – by Erik Swain
Disclosure: The ORBIT-AF registry is sponsored by Janssen Scientific Affairs. The researchers and Wyse report no relevant financial disclosures.
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