Mending the rhythm does not improve prognosis in patients with persistent atrial fibrillation: a subanalysis of the RACE study. Randomized Study Comparing Combined Pulmonary Vein–Left Atrial Junction Disconnection and Cavotricuspid Isthmus Ablation Versus Pulmonary Vein–Left Atrial Junction Disconnection Alone in Patients Presenting With Typical Atrial Flutter and Atrial Fibrillation Long-term efficacy and safety of two different rhythm control strategies in elderly patients with symptomatic persistent atrial fibrillation. Ablation for longstanding permanent atrial fibrillation: results from a randomized study comparing three different strategies. Atrial fibrillation: the rate versus rhythm management controversy. Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation: observations from the veterans affairs congestive heart failure survival trial of antiarrhythmic therapy (CHF-STAT). The Department of Veterans Affairs CHF-STAT Investigators. Functional status in rate- versus rhythm-control strategies for atrial fibrillation: results of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Functional Status Substudy. Improvements in Symptoms and Quality of Life in Patients With Paroxysmal Atrial Fibrillation Treated With Radiofrequency Catheter Ablation Versus Antiarrhythmic Drugs Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. Exercise Training in Patients With Chronic Heart Failure and Atrial Fibrillation. Propafenone versus sotalol for suppression of recurrent symptomatic atrial fibrillation. Relationships Between Sinus Rhythm, Treatment, and Survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study
AIMS To compare outcome of AF patients with effective rhythm control with patients treated with rate control .  METHODS AND RESULTS Out of the 266 AF patients r and omized to rhythm control in the RACE study , 49 patients turned to long-term sinus rhythm and were continuously treated with oral anticoagulation . The incidence of the primary endpoint in these patients was compared to that in 178 patients out of the initial 256 rate-control patients of RACE who were in AF and using oral anticoagulation continuously . Baseline characteristics of both groups were not different . After a mean follow-up of 2.3+/-0.6 years , the primary endpoint ( a composite of cardiovascular mortality , heart failure , thrombo-embolic complications ( TECs ) , bleeding , serious adverse effects of antiarrhythmic drugs and pacemaker implants ) was 22.4 % in the rhythm-control group vs. 15.2 % in the rate-control group . Multivariable regression analysis indicated coronary artery disease , heart failure , and digitalis as independent risk indicators of cardiovascular morbidity and mortality . Chronic sinus rhythm did not matter . CONCLUSION Among patients who remained on warfarin  , those who mostly were maintained in sinus rhythm under a rhythm-control strategy did not have a superior prognosis compared to those who remained in AF under a rate-control strategy Background —Atrial flutter ( AFL ) and atrial fibrillation ( AF ) frequently coexist in the same patient . Recently it has been demonstrated that the triggers for both AF and AFL may originate in the pulmonary veins ( PVs ) . We hypothesized that in patients with both AF and typical AFL , pulmonary vein – left atrial junction ( PV-LAJ ) disconnection may eliminate both arrhythmias . Methods and Results —Consecutive patients with documented symptomatic AF and typical AFL were r and omly assigned to have PV-LAJ disconnection combined with cavotricuspid isthmus ( CTI ) ablation ( group 1 , n=49 ) or PV-LAJ disconnection alone ( group 2 , n=59 ) . Within the first 8 weeks after ablation , 32 of the group 2 patients had typical AFL documented , whereas none was seen in group 1 . Twenty of these 32 converted to sinus rhythm after initiating antiarrhythmic drugs ( AADs ) . Twelve were cardioverted , and AADs were started . After 8 weeks , all AADS were stopped , and only 3 patients continued to have recurrent sustained typical AFL that was eliminated by CTI ablation . Beyond 8 weeks of follow-up , 7 patients in group 1 and 6 patients in group 2 ( 14 % and 11 % , respectively ) continued to have AF . Ten of these 13 patients underwent a repeat PV-LAJ disconnection procedure and were cured . The remaining 3 remained in normal sinus rhythm while taking AADs . Conclusions —In patients with both AFL and AF , PV-LAJ disconnection alone may be sufficient to control both arrhythmias . CTI block reduced early postablation recurrence of arrhythmias , which in the majority of patients reflects a short-term clinical problem BACKGROUND We prospect ively compared the efficacy , safety , and quality of life ( QoL ) impact of catheter ablation versus antiarrhythmic drugs ( AAD ) in elderly patients with persistent atrial fibrillation ( AF ) . METHODS AND RESULTS Four hundred and twelve consecutive patients , aged ≥ 70 years , underwent ablation ( Group A , 153 patients ) or AAD ( Group B , 259 patients ) . Study endpoints : treatment failure ( any AF/AT lasting > 30 seconds ) and treatment-related adverse events ( acute when ≤1 month of procedure and long term when > 1 month ) . At a follow-up of 60 ± 17 months , 43 % and 46 % patients in Group B versus 58 % and 76 % in Group A were in sinus rhythm ( SR ) , respectively , after one ( P = 0.003 ) and 2 procedures ( P < 0.001 ) . Fifteen acute adverse events occurred ( 6.7 % in Group A vs 1 % in Group B , P < 0.001 ) , mainly periprocedural cerebral thromboembolism ( 3.3 % in Group A vs 0.7 % in Group B , P = 0.058 ) . Previous TIA/stroke result ed the only independent predictor of periprocedural cerebrovascular accidents ( OR 1.2 , 95%IC 1.1 - 1.3 ) . At follow-up , 74 long-term adverse events occurred ( 7.7 % in Group A vs 23.9 % in Group B , P < 0.001 ) with Group B patients more often experiencing  AAD-related  adverse events ( 12.7 % vs 2.6 % , P < 0.001 ) . Group A and absence of AF/AT recurrences significantly improved QoL scores ( P < 0.001 ) . CONCLUSIONS In elderly persistent AF patients  , catheter ablation is more effective in maintaining SR and in improving QoL  than AAD but is affected by a higher risk of embolic complications , particularly in patients with previous TIA/stroke . Over time , Group A patients more likely discontinued AAD with a reduction of long-term adverse events BACKGROUND This prospect i ve multicenter r and omized study aim ed to compare the efficacy of 3 common ablation methods used for longst and ing permanent atrial fibrillation ( AF ) . METHODS A total of 144 patients with longst and ing permanent AF ( median duration 28 months ) were r and omly assigned to circumferential pulmonary vein ablation ( CPVA , group 1 , n = 47 ) , to pulmonary vein antrum isolation ( PVAI , group 2 , n = 48 ) or to a hybrid strategy combining ablation of complex fractionated or rapid atrial electrograms ( CFAE ) in both atria followed by a pulmonary vein antrum isolation ( CFAE + PVAI , group 3 , n = 49 ) . RESULTS Scarring in the left atrium and structural heart disease/hypertension were present in most patients ( 65 % ) . After a mean follow-up of 16 months , 11 % of patients in group 1 , 40 % of patients in group 2 and 61 % of patients in group 3 were in sinus rhythm after one procedure and with no antiarrhythmic drugs ( P < .001 ) . Sinus rhythm maintenance would increase respectively to 28 % ( group 1 ) , 83 % ( group 2 ) , and 94 % ( group 3 ) after 2 procedures and with antiarrhythmic drugs ( AADs , P < .001 ) . The AF terminated during ablation , either by conversion to sinus rhythm or organization into an atrial tachyarrhythmia , in 13 % of patients ( group 1 ) , 44 % ( group 2 ) , and 74 % ( group 3 ) respectively . CFAE alone , performed as the first step of the ablation in group 3 , organized AF in only 1 patient . CONCLUSION In this study , the hybrid AF ablation strategy including antrum isolation and CFAE ablation had the highest likelihood of maintaining sinus rhythm in patients with longst and ing permanent AF . Electrical isolation of the PVs , although inadequate if performed alone , is relevant to achieve long-term sinus rhythm maintenance after ablation . Bi-atrial CFAE ablation had a minimal impact on AF termination during ablation The fundamental management strategy for atrial fibrillation ( AF ) is still debated . There is no doubt that those patients at risk of thromboembolic events should be offered anticoagulant therapy . However , it is uncertain whether rhythm control ( restoration and maintenance of sinus rhythm ) or rate control ( adjustment to a physiological ventricular rate while allowing AF to continue ) is the preferred primary treatment option for the reduction of symptoms and major cardiovascular ( CV ) outcomes associated with AF . Several well conducted trials comparing the two strategies led to the conclusion that there was little to choose between them . However , guidelines leaned towards recommending rate control as the initial strategy , and reserved rhythm control for those who remained symptomatic . Recently this status quo is being increasingly challenged by the clear demonstration that left atrial catheter ablation is effective at suppressing AF resistant to traditional antiarrhythmic drugs , such as those that failed to demonstrate any superiority when compared with rate control . Also , recently introduced antiarrhythmic therapy may have superior efficacy with regard to reducing unexpected CV hospitalization , CV mortality and stroke . In addition , there is a growing perception that atrial remodelling should be best prevented by early rhythm control rather than delaying until rate control has proven unsatisfactory . For these reasons the results of large r and omised clinical trials , which recruit patients soon after the presentation of AF and compare ' aggressive ' modern rhythm control against the guideline approach of primary rate control , are eagerly awaited . In the meantime the pendulum of clinical opinion has begun to swing towards a rhythm control strategy BACKGROUND In a multicenter , double-blind , placebo-controlled study , the long-term effects of amiodarone on morbidity and mortality in patients with congestive heart failure ( CHF ) and atrial fibrillation ( AF ) were evaluated during a 4-year period . METHODS AND RESULTS Of 667 patients with CHF , 103 ( 15 % ) had AF at baseline . Of these , 51 were r and omized to amiodarone and 52 to placebo . The group with sinus rhythm and the group in AF were comparable except for a higher proportion of AF in patients with nonischemic versus ischemic cardiomyopathy ( 41 % versus 27 % , P<0.005 ) . The mean ventricular response ( VR ) during AF over 24 hours was reduced by amiodarone at 2 weeks ( 20 % , P=0.001 ) , at 6 months ( 18 % , P=0.001 ) , and at 12 months ( 16 % , P=0.006 ) . Maximal VR was reduced 22 % ( P=0.001 ) at 2 weeks , 19 % ( P=0.001 ) at 6 months , and 14 % ( P=0.001 ) at 12 months . Sixteen of 51 patients on amiodarone and 4 of 52 on placebo converted to sinus rhythm during the study ( chi2=9.23 , P=0.002 ) . During follow-up , 11 of 268 patients in sinus rhythm on amiodarone at baseline and 22 of the 263 in sinus rhythm on placebo developed AF ; the difference was significant ( chi2=12.88 , P=0.005 ) . Analysis of total mortality during follow-up showed a significantly lower mortality rate ( P=0 . 04 ) in patients in AF at baseline who subsequently converted to sinus rhythm on amiodarone than in those who did not convert to sinus rhythm on the drug . CONCLUSIONS In patients with CHF , amiodarone has a significant potential to spontaneously convert patients in AF to sinus rhythm , with patients who convert having a lower mortality rate than those who do not . The drug prevented the development of new-onset AF and significantly reduced the VR in those with persistent AF OBJECTIVES The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) functional status sub study aim ed to test the hypothesis that functional status is similar in rate-control and rhythm-control strategies . BACKGROUND R and omized studies , including the AFFIRM study , have failed to demonstrate survival benefits between rate-control and rhythm-control strategies for atrial fibrillation ( AF ) . However , AF may cause functional capacity or cognitive impairment that might justify maintenance of sinus rhythm . METHODS Investigators of the AFFIRM study enrolled 4,060 patients with AF who required long-term therapy and who were 65 years of age or older or who had another risk factor for stroke or death . New York Heart Association functional class ( NYHA-FC ) and Canadian Cardiovascular Society Angina Classification were assessed at initial and each follow-up visit . From 22 r and omly chosen functional status sub study sites , 245 participants underwent  6-min walk tests and Mini-Mental State Examination ( MMSE ) at initial , two-month , and yearly visits . Patients were assigned r and omly to rate-controlling drugs , allowing AF to persist , or rhythm-controlling antiarrhythmic drugs , to maintain sinus rhythm . RESULTS The NYHA-FC worsened with time in both rate-control and rhythm-control groups , with no differences between groups . Presence of AF was associated with worse NYHA-FC ( p < 0.0001 ) . No differences were observed in Canadian Cardiovascular Society Angina Classification or MMSE scores . Six-minute walk distance improved over time in both study arms . On average , walk distance was 94 feet greater in the rhythm-control group ( adjusted p = 0.049 ) . CONCLUSIONS Modest improvement in 6-min walk distance was noted in the rhythm-control arm . Presence of AF was associated with worse NYHA-FC . No difference in cognitive function was detected Background —In patients with paroxysmal atrial fibrillation ( AF ) , catheter ablation maintains sinus rhythm more effectively than antiarrhythmic drugs ( AADs ) , but its effect on symptoms and quality of life ( QOL ) has not been fully characterized . Methods and Results —We evaluated symptoms and QOL in a multicenter , r and omized trial comparing catheter ablation with AADs as second-line treatment for patients with paroxysmal AF . The Short Form (SF)-36 health survey and the AF Symptom Checklist were administered at baseline and 3 , 6 , and 9 months after a blanking or dose-titration period . The primary between-group comparisons were conducted at 3 months because of permitted crossover from AAD to ablation beyond this time . Additional analyses based on subsequent follow-up were performed , including the construction of mixed linear regression models to assess the impact of multiple factors on follow-up QOL scores . At baseline in both the ablation ( n=103 ) and the AAD ( n=56 ) groups , 7 of 8 SF-36 scales were well below population norms , as were the physical ( PCS ) and mental ( MCS ) summary scores . At 3 months , the same 7 SF-36 scales were significantly ( P<0.01 ) higher in the ablation than in the AAD group , as were the PCS ( 52.0±7.8 versus 47.1±10.6 ; P<0.01 ) and MCS ( 52.4±8.1 versus 46.6±9.8 ; P<0.01 ) scores , whereas symptom frequency ( 9.3±9.2 versus 19.0±12.6 ; P<0.001 ) and symptom severity ( 7.7±7.2 versus 16.2±10.0 ; P<0.001 ) were significantly reduced . In multivariable analysis , ablation and recurrent arrhythmias most strongly correlated with QOL changes over time . Conclusions —For second-line therapy of paroxysmal AF , ablation is superior to AAD treatment at improving symptoms and QOL . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00116428 OBJECTIVES This study was design ed to compare two treatment strategies in patients with atrial fibrillation(AF ) :  rhythm-control ( restoration and maintenance of sinus rhythm ) and rate-control ( pharmacologic or invasive rate-control and anticoagulation ) . BACKGROUND Atrial fibrillation is the most common arrhythmia . It is unclear whether a strategy of rhythm- or rate-control is better in terms of mortality , morbidity , and quality of life . METHODS The Strategies of Treatment of Atrial Fibrillation ( STAF ) multicenter pilot trial r and omized 200 patients ( 100 per group ) with persistent AF to rhythm- or rate-control .  The combined primary end point was a combination of death , cardiopulmonary resuscitation , cerebrovascular event , and systemic embolism . RESULTS After 19.6 + /- 8.9 months ( range 0 to 36 months ) there was no difference in the primary end point between rhythm-control ( 9/100 ; 5.54%/year ) and rate-control ( 10/100 ; 6.09%/year ; p = 0.99 ) . The percentage of patients in sinus rhythm in the rhythm-control group after up to four cardioversions during the follow-up period ( rate-control group ) was 23 % ( 0 % ) at 36 months . Eighteen primary end points occurred in atrial fibrillation ; only one occurred in sinus rhythm ( p = 0.049 ) . CONCLUSIONS The STAF pilot study showed no differences between the two treatment strategies in all end points except hospitalizations . These data suggest that there was no benefit in attempting rhythm-control in these patients with a high risk of arrhythmia recurrence . It remains unclear whether the results in the rhythm-control group would have been better if sinus rhythm had been maintained in a higher proportion of patients , as all but one end point occurred during AF BACKGROUND The safety and efficacy of aerobic exercise in heart failure ( HF ) patients with atrial fibrillation ( AF ) has not been well evaluated . OBJECTIVES This study examined whether outcomes with exercise training in HF vary according to AF status . METHODS HF-ACTION ( Heart Failure : A Controlled Trial Investigating Outcomes of Exercise Training ) r and omized 2,331 ambulatory HF patients with ejection fraction ≤35 % to exercise training or usual care .  We examined clinical characteristics and outcomes ( mortality/hospitalization ) by baseline AF status ( past history of AF or AF on baseline electrocardiogram vs. no AF ) using adjusted Cox models and explored an interaction with exercise training . We assessed post-r and omization AF events diagnosed via hospitalizations for AF and reports of serious arrhythmia caused by AF . RESULTS Of 2,292 patients with baseline rhythm data , 382 ( 17 % ) had AF , 1,602 ( 70 % ) had sinus rhythm , and 308 ( 13 % ) had " other " rhythm . Patients with AF were older and had lower peak Vo2 . Over a median follow-up of 2.6 years , AF was associated with a 24 % per year higher rate of mortality/hospitalization ( hazard ratio [ HR ] : 1.53 ; 95 % confidence interval [ CI ] : 1.34 to 1.74 ; p < 0.001 ) in unadjusted analysis ; this did not remain significant after adjustment ( HR : 1.15 ; 95 % CI : 0.98 to 1.35 ; p = 0.09 ) . There was no significant difference in AF event rates by r and omized treatment assignment in the overall population or by baseline AF status ( all p > 0.10 ) . There was no interaction between AF and exercise training on measures of functional status or clinical outcomes ( all p > 0.10 ) . CONCLUSIONS AF in patients with chronic HF was associated with older age , reduced exercise capacity at baseline , and a higher overall rate of clinical events , but not a differential response to exercise training for clinical outcomes or changes in exercise capacity . ( Heart Failure : A Controlled Trial Investigating Outcomes of Exercise Training [ HF-ACTION ] ; NCT00047437 ) Because conventional antiarrhythmic therapy is often ineffective in maintaining sinus rhythm or is associated with adverse side effects in patients with atrial fibrillation ( AF ) , there is a clinical need to test newer agents . One hundred patients with AF who had unsuccessful therapy with 1.9 + /- 1.0 type IA antiarrhythmic agents were r and omized to receive either propafenone ( n = 50 ) or sotalol ( n = 50 ) . Patients were stratified into 4 groups based on AF pattern ( chronic vs paroxysmal ) and left atrial size ( large [ > or = 4.5 cm ] vs small [ < 4.5 ] ) . The proportion of patients remaining in sinus rhythm on each agent was calculated for each group by the Kaplan-Meier method . For patients r and omized to propafenone , 46 + /- 8 % , 41 + /- 8 % and 30 + /- 8 % remained in sinus rhythm at 3 , 6 and 12 months , respectively , after cardioversion . A similar proportion of patients treated with sotalol remained in sinus rhythm at follow-up ( 49 + /- 7 % , 46 + /- 8 % and 37 + /- 8 % at 3 , 6 and 12 months , respectively ; p = NS ) . The proportion of patients remaining in sinus rhythm on propafenone and sotalol was not dependent on arrhythmia pattern or left atrial dimension . Except for constipation that occurred more frequently in patients treated with propafenone , adverse side effects were equally distributed between the 2 therapies . Two patients receiving sotalol died during follow-up . Propafenone and sotalol , 2 new antiarrhythmic agents , were found to be equally effective in maintaining sinus rhythm in 100 patients with recurrent AF . Response rates were not affected by arrhythmia pattern , left atrial size or unsuccessful prior drug therapy . ( ABSTRACT TRUNCATED AT 250 WORDS Background —The AFFIRM Study showed that treatment of patients with atrial fibrillation and a high risk for stroke or death with a rhythm-control strategy offered no survival advantage over a rate-control strategy in an intention-to-treat analysis . This article reports an “ on-treatment ” analysis of the relationship of survival to cardiac rhythm and treatment as they changed over time . Methods and Results —Modeling techniques were used to determine the relationships among survival , baseline clinical variables , and time-dependent variables . The following baseline variables were significantly associated with an increased risk of death : increasing age , coronary artery disease , congestive heart failure , diabetes , stroke or transient ischemic attack , smoking , left ventricular dysfunction , and mitral regurgitation . Among the time-dependent variables , the presence of sinus rhythm ( SR ) was associated with a lower risk of death , as was warfarin use . Antiarrhythmic drugs ( AADs ) were associated with increased mortality only after adjustment for the presence of SR . Consistent with the original intention-to-treat analysis , AADs were no longer associated with mortality when SR was removed from the model . Conclusions —Warfarin use improves survival . SR is either an important determinant of survival or a marker for other factors associated with survival that were not recorded , determined , or included in the survival model . Currently available AADs are not associated with improved survival , which suggests that any beneficial antiarrhythmic effects of AADs are offset by their adverse effects . If an effective method for maintaining SR with fewer adverse effects were available , it might be beneficial
As such , evidence was insufficient to recommend rhythm or rate control as the first-line therapy for AF in older adults .
Atrial fibrillation ( AF ) is highly prevalent in older adults and has been associated with increased morbidity and mortality .
To reduce this AF-related morbidity in older adults , antiarrhythmic drugs ( AADs ) are regularly used for rhythm control , assuming that increasing time in sinus rhythm reduces AF-related morbidity .
However , whether AADs can improve clinical outcomes in older adults remains unclear because of the increased risk for adverse drug events compared with rate control .
The aim of this study was to determine the impact of rhythm control versus rate control on clinical outcomes in older adults with AF .