Rate, rhythm control strategies both effective in treating postoperative AF

CHICAGO —Both rate and rhythm control strategies are safe and effective for patients in atrial fibrillation after cardiac surgery, according to data presented at the American College of Cardiology Scientific Session.

“There was no clear advantage of rate or rhythm control strategy,” A. Marc Gillinov, MD, a cardiac surgeon at the Cleveland Clinic, said during a press conference. “There were equal days in the hospital, similar complication rates and low rates of persistent AF 60 days after onset. However, those in rhythm control returned to sinus rhythm quicker.”

A. Marc Gillinov

Gillinov and colleagues randomized 523 patients (mean age, 69 years; 24% women) from 23 academic medical centers in the U.S. and Canada to either rate-control (n = 262) or rhythm-control (n = 261) strategies. Inclusion criteria were onset of AF during index hospitalization within the first 7 days of surgery and either AF or atrial flutter persisting more than 60 minutes or recurrent episodes of AF or atrial flutter. The primary endpoint was the total number of days of hospitalization within 60 days after randomization.

The study was simultaneously published in the New England Journal of Medicine.

Both strategies safe, effective

Patients in the rate-control group had a median total number of hospital days of 5.1 vs. 5 in the rhythm-control group (P = .76). There were no significant differences between the two groups in mortality (P = .64) or serious adverse events (P = .61).

However, approximately 25% of patients in each group did not adhere to the assigned therapy. For those in the rate-control group, drug ineffectiveness was the main cause. In the rhythm-control group, it was mostly due to amiodarone side effects or adverse drug reactions, according to the researchers.

At 60 days, stable heart rhythm without AF was achieved in 93.8% of patients in the rate-control group and 97.9% of patients in the rhythm-control group for the previous 30 days (P = .02). In addition, 84.2% of patients in the rate-control group and 86.9% of those in the rhythm-control group were free from AF from discharge to 60 days (P = .41).

Clinical differences observed

Some clinical differences between the two groups were that those in the rhythm-control group were slightly more likely to be free of AF at 60 days, but they were also more likely to experience adverse events from amiodarone. Those in the rate-control group experienced fewer side effects, but were slightly more likely to still be in AF at 60 days, according to the researchers.

“Patient and physician preferences should inform treatment choice, but an initial strategy of rate control in hemodynamically stable patients with postoperative AF is reasonable,” Gillinov said. – by Tracey Romero

Reference:

Gillinov AM, et. al. Joint ACC/NEJM Late-Breaking Clinical Trials. Presented at: American College of Cardiology Scientific Session; April 2-4, 2016; Chicago.

Gillinov AM, et al. N Engl J Med. 2016; doi:10.1056/NEJMoa1602002.

Disclosure: Gillinov reports receiving consulting fees from Abbott, AtriCure, Edwards, Medtronic and On-X. He also reports research funding from St. Jude Medical and Tendyne and equity interest in Clear Catheter. Cleveland Clinic reports the right to receive royalties from AtriCure for a left atrial appendage occlusion device. Please see full study for list of all other authors’ relevant financial disclosures.