Impact of rate control medications on one-year outcomes with atrial fibrillation and heart failure

Abstract Purpose Atrial fibrillation (AF) and heart failure (HF) often coexist. The impact of rate-control regimens in AF and HF patients has not been well understood. Methods In this multicenter, prospective registry with one-year follow-up, 1359 persistent or permanent AF patients got enrolled. A 1:1 HF to non-HF propensity score matching was applied to adjust for confounding variables. The primary endpoint was all-cause mortality while the secondary endpoint was defined as cardiovascular death and stroke. Multivariate Cox analysis was performed to evaluate the association between different rate-control treatment and incidence of adverse events. Results Before matching, HF patients were much younger and more likely to be female. They had a much higher prevalence of previous myocardial infarction, chronic obstructive pulmonary disease and valvular heart disease. Among 1359 participants, we identified 1016 matched patients. The number of drugs did not affect the risk of all-cause mortality in both cohorts. For non-HF patients, using calcium channel blockers (CCBs) plus digoxin had a significant higher risk of all-cause death (HR=5.703, 95% CI 1.334–24.604, p=0.019) and cardiovascular death (HR=9.558, 95% CI 2.127–42.935, p=0.003) compared with patients not receiving rate-control treatment. The use of beta-blockers, CCBs, digoxin alone, other dual or triple combinations was not related to risk of adverse events in both groups. Conclusions The combined use of CCBs and digoxin was related to increase all-cause and cardiovascular mortality in AF patients without HF but not for those with HF. However, the ideal rate-control regimen for AF and HF patients has not been established and well-designed clinical trials are needed. FUNDunding Acknowledgement Type of funding sources: None. Results of multivariate Cox analysis Kaplan-Meier curves by drug numbers

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Gender-Related Differences In Treatment Patterns And Outcomes of Patients With Atrial Fibrillation: Insights From The MISOAC-AF Trial

10.21203/rs.3.rs-772332/v1 ◽

2021 ◽

Author(s):

Ioannis Vouloagkas ◽

Anastasios Kartas ◽

Athanasios Samaras ◽

Andreas S. Papazoglou ◽

Dimitrios V. Moysidis ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Rate Control ◽

Cox Regression ◽

Cardiovascular Death ◽

Treatment Patterns ◽

Rhythm Control ◽

Vitamin K Antagonist ◽

Control Treatment ◽

All Cause Mortality

Abstract PurposeTo assess the gender-related differences in the treatment patterns of patients with atrial fibrillation (AF), and their prognostic value.MethodsIn this post-hoc analysis of a randomized controlled trial, 1140 hospitalized patients with comorbid AF were followed-up for a median of 2.6 years. Kaplan-Meier and multivariable Cox-regression analyses assessed the adjusted hazard ratios (aHRs) for outcomes in males and females, according to oral anticoagulation (OAC) type (vitamin K antagonist or non-vitamin K antagonist oral anticoagulants), rhythm or rate control treatment. The primary outcome was all-cause mortality and the secondary outcomes were stroke and the composite of any hospitalization or cardiovascular death. ResultsAmong 622 males and 518 females, use of OAC (61% vs 62%), rate control (56% vs 57%), and rhythm control (31% vs 28%) treatments was similar (all p>0.05). In males, use of rate control, as compared with rhythm control, was independently associated with higher rates of all-cause mortality (aHR=2.06; 95% confidence interval [CI] 1.24-3.41) and the composite of hospitalization or cardiovascular death (aHR=1.34, 95% CI 1.01-1.85). In females, use of rhythm control was significantly associated with higher rates of hospitalization-or cardiovascular mortality (aHR=1.74, 95% CI 1.03-2.94). Among genders, stroke rates were similar regardless of OAC type, rate or rhythm control treatment.ConclusionsIn patients discharged from the hospital with comorbid AF, the use of OAC, rhythm or rate control treatment was similar among genders. However, males seemed to benefit more from rhythm, whereas females from rate control treatment.

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Comparative Effectiveness of Early Rhythm Control Versus Rate Control for Cardiovascular Outcomes in Patients With Atrial Fibrillation

Journal of the American Heart Association ◽

10.1161/jaha.121.023055 ◽

2021 ◽

Author(s):

Daehoon Kim ◽

Pil‐Sung Yang ◽

Seng Chan You ◽

Eunsun Jang ◽

Hee Tae Yu ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Atrial Fibrillation ◽

Rate Control ◽

Cardiovascular Death ◽

Population Based ◽

Cardiovascular Outcomes ◽

Rhythm Control ◽

Control Treatment ◽

Control Rhythm

Background Rhythm control is associated with better cardiovascular outcomes than usual care among patients with recently diagnosed atrial fibrillation (AF). This study investigated the effects of rhythm control compared with rate control on the incidence of stroke, heart failure, myocardial infarction, and cardiovascular death stratified by timing of treatment initiation. Methods and Results We conducted a retrospective population‐based cohort study including 22 635 patients with AF newly treated with rhythm control (antiarrhythmic drugs or ablation) or rate control in 2011 to 2015 from the Korean National Health Insurance Service database. Propensity overlap weighting was used. Compared with rate control, rhythm control initiated within 1 year of AF diagnosis decreased the risk of stroke. The point estimates for rhythm control initiated at selected time points after AF diagnosis are as follows: 6 months (hazard ratio [HR], 0.76; 95% CI, 0.66–0.87), 1 year (HR, 0.78; 95% CI, 0.66–0.93), and 5 years (HR, 1.00; 95% CI, 0.45–2.24). The initiation of rhythm control within 6 months of AF diagnosis reduced the risk of hospitalization for heart failure: 6 months (HR, 0.84; 95% CI, 0.74–0.95), 1 year (HR, 0.96; 95% CI, 0.82–1.13), and 5 years (HR, 2.88; 95% CI, 1.34–6.17). The risks of myocardial infarction and cardiovascular death did not differ between rhythm and rate control regardless of treatment timing. Conclusions Early initiation of rhythm control was associated with a lower risk of stroke and heart failure–related admission than rate control in patients with recently diagnosed AF. The effects were attenuated as initiating the rhythm control treatment later.

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Cardiovascular risk after hospitalisation for unexplained syncope and orthostatic hypotension

Heart ◽

10.1136/heartjnl-2017-311857 ◽

2017 ◽

Vol 104 (6) ◽

pp. 487-493 ◽

Cited By ~ 14

Author(s):

Ekrem Yasa ◽

Fabrizio Ricci ◽

Martin Magnusson ◽

Richard Sutton ◽

Sabina Gallina ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Cardiovascular Disease ◽

Orthostatic Hypotension ◽

Cardiovascular Events ◽

Hospital Admissions ◽

Cox Regression ◽

All Cause Mortality ◽

Unexplained Syncope ◽

The Impact

ObjectiveTo investigate the relationship of hospital admissions due to unexplained syncope and orthostatic hypotension (OH) with subsequent cardiovascular events and mortality.MethodsWe analysed a population-based prospective cohort of 30 528 middle-aged individuals (age 58±8 years; males, 40%). Adjusted Cox regression models were applied to assess the impact of unexplained syncope/OH hospitalisations on cardiovascular events and mortality, excluding subjects with prevalent cardiovascular disease.ResultsAfter a median follow-up of 15±4 years, 524 (1.7%) and 504 (1.7%) participants were hospitalised for syncope or OH, respectively, yielding 1.2 hospital admissions per 1000 person-years for each diagnosis. Syncope hospitalisations increased with age (HR, per 1 year: 1.07, 95% CI 1.05 to 1.09), higher systolic blood pressure (HR, per 10 mm Hg: 1.06, 95% CI 1.01 to 1.12), antihypertensive treatment (HR: 1.26, 95% CI 1.00 to 1.59), use of diuretics (HR: 1.77, 95% CI 1.31 to 2.38) and prevalent cardiovascular disease (HR: 1.59, 95% CI 1.14 to 2.23), whereas OH hospitalisations increased with age (HR: 1.11, 95% CI 1.08 to 1.12) and prevalent diabetes (HR: 1.82, 95% CI 1.23 to 2.70). After exclusion of 1399 patients with prevalent cardiovascular disease, a total of 473/464 patients were hospitalised for unexplained syncope/OH before any cardiovascular event. Hospitalisation for unexplained syncope predicted coronary events (HR: 1.85, 95% CI 1.49 to 2.30), heart failure (HR: 2.24, 95% CI 1.65 to 3.04), atrial fibrillation (HR: 1.84, 95% CI 1.50 to 2.26), aortic valve stenosis (HR: 2.06, 95% CI 1.28 to 3.32), all-cause mortality (HR: 1.22, 95% CI 1.09 to 1.37) and cardiovascular death (HR: 1.72, 95% CI 1.23 to 2.42). OH-hospitalisation predicted stroke (HR: 1.66, 95% CI 1.24 to 2.23), heart failure (HR: 1.78, 95% CI 1.21 to 2.62), atrial fibrillation (HR: 1.89, 95% CI 1.48 to 2.41) and all-cause mortality (HR: 1.14, 95% CI 1.01 to 1.30).ConclusionsPatients discharged with the diagnosis of unexplained syncope or OH show higher incidence of cardiovascular disease and mortality with only partial overlap between these two conditions.

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The impact of atrial fibrillation on one-year mortality in patients with severe lower extremity arterial disease

10.21203/rs.3.rs-243651/v1 ◽

2021 ◽

Author(s):

Min-I Su ◽

Cheng-Wei Liu

Keyword(s):

Atrial Fibrillation ◽

Lower Extremity ◽

Oral Anticoagulants ◽

Arterial Disease ◽

Major Adverse Cardiovascular Events ◽

Acute Limb Ischemia ◽

Lower Extremity Arterial Disease ◽

All Cause Mortality ◽

One Year ◽

The Impact

Abstract Backgroundand Aims: Atrial fibrillation (Afib) is associated with the incidence of lower extremity arterial disease (LEAD), but its effect on severe LEAD prognosis remains unclear. We investigated the association between Afib and clinical outcomes.Methods and ResultsWe retrospectively enrolled consecutive severe LEAD patients receiving percutaneous transluminal angioplasty between 2013/1/1 and 2018/12/31. Patients were divided by a history of any type of Afib and followed for at least one year. The primary outcome was all-cause mortality. Secondary outcomes were cardiac-related mortality, major adverse cardiovascular events (MACEs), and major adverse limb events (MALEs). The study included 222 patients aged 74 ± 11 years (54% male), and 12.6% had acute limb ischemia. The Afib group had significantly higher rates of all-cause mortality (42.9% vs. 20.1%, P = 0.014) and MACEs (32.1% vs. 14.4%, P = 0.028) than the non-Afib group. After adjustment for confounders, Afib was independently associated with all-cause mortality (adjusted HR: 2.153, 95% CI: 1.084–4.276, P = 0.029) and MACEs (adjusted HR: 2.338, 95% CI: 1.054–2.188, P = 0.037).ConclusionsAfib was significantly associated with increased risks of one-year all-cause mortality and MACEs in severe LEAD patients. Future studies should investigate whether oral anticoagulants benefit these patients.

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Abstract P369: Polypharmacy, Adverse Outcomes, and Treatment Effectiveness in Elderly Patients With Atrial Fibrillation

Circulation ◽

10.1161/circ.141.suppl_1.p369 ◽

2020 ◽

Vol 141 (Suppl_1) ◽

Cited By ~ 1

Author(s):

Aniqa Alam ◽

Nemin Chen ◽

Pamela L Lutsey ◽

Richard MacLehose ◽

J'Neka Claxton ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

Elderly Patients ◽

Rate Control ◽

Treatment Effectiveness ◽

Adverse Outcomes ◽

Pharmacy Claims ◽

Increased Risk ◽

The Impact

Background: Polypharmacy is highly prevalent in elderly individuals with chronic conditions, including atrial fibrillation (AF). The impact of polypharmacy on adverse outcomes and on treatment effectiveness in elderly AF patients remains unaddressed. Methods: We studied 338,810 AF patients ≥75 years of age with 1,761,660 active prescriptions [mean (SD), 5.1 (3.8) per patient] enrolled in the MarketScan Medicare Supplemental database in 2007-2015. Polypharmacy was defined as ≥5 active prescriptions at AF diagnosis based on outpatient pharmacy claims. AF treatments (oral anticoagulation, rhythm and rate control) and cardiovascular endpoints (ischemic stroke, bleeding, heart failure) were defined based on inpatient, outpatient and pharmacy claims. Multivariable Cox models were used to estimate associations of polypharmacy with cardiovascular endpoints and the interaction between polypharmacy and AF treatments in relation to cardiovascular endpoints. Results: Prevalence of polypharmacy was 52% (176,007 of 338,810). Patients with polypharmacy had increased risk of major bleeding [hazard ratio (HR) 1.16, 95% confidence interval (CI) 1.12, 1.20] and heart failure (HR 1.33, 95%CI 1.29, 1.36), but not of ischemic stroke (HR 0.96, 95%CI 0.92, 1.00), compared to those not with polypharmacy (Table). Polypharmacy status did not consistently modify the effectiveness of oral anticoagulants. However, rhythm control (vs. rate control) was more effective in preventing heart failure hospitalization in patients not with polypharmacy (HR 0.87, 95%CI 0.76, 0.99) than among those with polypharmacy (HR 0.98, 95%CI 0.91, 1.07, p for interaction = 0.02). Conclusion: Polypharmacy is frequent among elderly patients with AF, associated with adverse outcomes, and potentially affecting the effectiveness of AF treatments. Optimizing management of polypharmacy in elderly AF patients may lead to improved outcomes.

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3153Rate versus rhythm control and mortality in atrial fibrillation patients: a Danish nationwide cohort study

European Heart Journal ◽

10.1093/eurheartj/ehz745.0041 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

F Dalgaard ◽

S Al-Khatib ◽

J Pallisgaard ◽

C Torp-Pedersen ◽

T B Lindhardt ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Heart Disease ◽

Control Strategy ◽

Rate Control ◽

Channel Blocker ◽

Rhythm Control ◽

All Cause Mortality ◽

Control Therapy

Abstract Background Treatment of AF patients with rate or rhythm drug therapy have shown no difference in mortality in clinical trials. However, the generalizability of these trials to real-world populations can be questioned. Purpose We aimed to investigate the all-cause and cardiovascular (CV) mortality risk in a nationwide AF cohort by treatment strategy (rate vs. rhythm) and by individual drug classes. Methods We queried the Danish nationwide registries from 2000 to 2015 to identify patients with AF. A rate control strategy included the use of one or more of the following medications: beta-blocker, digoxin, and a class-4 calcium channel blocker (CCB). A rhythm control strategy included the use of an anti-arrhythmic drug (amiodarone and class-1C). Primary outcome was all-cause mortality. Secondary outcome was CV mortality. Adjusted incidence rate ratios (IRR) were computed using Poisson regression with time-dependent covariates allowing patients to switch treatment during follow-up. Results Of 140,697 AF patients, 131,793 were on rate control therapy and n=8,904 were on rhythm control therapy. At baseline, patients on rhythm control therapy were younger (71 yrs [IQR: 62–78] vs 74 [65–82], p<0.001) more likely male (63.5% vs 51.7% p<0.001), had more prevalent heart failure (31.1% vs 19.4%, p<0.001) and ischemic heart disease (40.1% vs. 23.3%, p<0.001), and had more prior CV-related procedures; PCI (7.4% vs. 4.0% p<0.001) and CABG (15.0% vs. 2.3%, p<0.001). During a median follow up of 4.0 (IQR: 1.7–7.3) years, there were 64,653 (46.0%) deaths from any-cause, of which 27,025 (19.2%) were CVD deaths. After appropriate adjustments and compared to rate control therapy, we found a lower IRR of mortality and CV mortality in those treated with rhythm control therapy (IRR: 0.93 [95% CI: 0.90–0.97] and IRR 0.84 [95% CI: 0.79–0.90]). Compared with beta-blockers, digoxin was associated with increased risk of all-cause and CV mortality (IRR: 1.26 [95% CI: 1.24–1.29] and IRR: 1.32 [95% CI: 1.28–1.36]), so was amiodarone: IRR for all-cause mortality: 1.16 [95% CI: 1.11–1.21] and IRR for CV mortality: 1.12 [95% CI: 1.05–1.19]. Class-1C was associated with lower all-cause (0.43 [95% CI: 0.37–0.49]) and CV mortality (0.35 [95% CI: 0.28–0.44]). Figure 1. Models were adjusted for age, sex, ischemic heart disease, stroke, chronic obstructive pulmonary disease, chronic kidney disease, valvular atrial fibrillation, bleeding, diabetes, ablation, pacemaker, implantable cardioverter defibrillator, hypertension, heart failure, use of loop diuretics, calendar year, and time on treatment. Abbreviations; CCB; calcium channel blocker, PY; person years. Conclusions In a real-world AF cohort, we found that compared with rate control therapy, rhythm control therapy was associated with a lower risk of all-cause and CV mortality. The reduced mortality risk with rhythm therapy could reflect an appropriate patient selection. Acknowledgement/Funding The Danish Heart Foundation

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P6361Prognostic value of discharge heart rate in acute heart failure patients: more relevant in atrial fibrillation?

European Heart Journal ◽

10.1093/eurheartj/ehz746.0957 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

R Vidal-Perez ◽

R Agra-Bermejo ◽

D Pascual-Figal ◽

F Gude Sampedro ◽

C Abou Jokh ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Heart Rate ◽

Sinus Rhythm ◽

Acute Heart Failure ◽

Left Ventricular Ejection ◽

Long Term Outcomes ◽

All Cause Mortality ◽

One Year

Abstract Background The prognostic impact of heart rate (HR) in acute heart failure (AHF) patients is not well known especially in atrial fibrillation (AF) patients. Purpose The aim of the study was to evaluate the impact of admission HR, discharge HR, HR difference (HRD) (admission- discharge) in AHF patients with sinus rhythm (SR) or AF on long- term outcomes. Methods We included 1398 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentric, prospective registry. Logistic regression models were used to estimate the association between admission HR, discharge HR and HR difference and one- year all-cause mortality and HF readmission. Results The mean age of the study population was 72±12 years. Of these, 594 (42.4%) were female, 655 (77.8%) were hypertensive and 655 (46.8%) had diabetes. Among all included patients, 745 (53.2%) had sinus rhythm and 653 (46.7%) had atrial fibrillation. Only discharge HR was associated with one-year all-cause mortality (Relative risk (RR)= 1.182, confidence interval (CI) 95% 1.024–1.366, p=0.022) in SR. In AF patients discharge HR was associated with one-year all-cause mortality (RR= 1.276, CI 95% 1.115–1.459, p≤0.001). We did not observe a prognostic effect of admission HR or HRD on long-term outcomes in both groups. This relationship is not dependent on left ventricular ejection fraction (Figure 1) Effect of post-discharge heart rate Conclusions In AHF patients lower discharge HR, neither the admission nor the difference, is associated with better long-term outcomes especially in AF patients Acknowledgement/Funding Heart Failure Program of the Red de Investigaciόn Cardiovascular del Instituto de Salud Carlos III, Madrid, Spain (RD12/0042) and the Fondo Europeo de

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Rhythm control in patients with atrial fibrillation and heart failure: a meta-analysis of randomized controlled trials

European Heart Journal ◽

10.1093/eurheartj/ehab724.0890 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

S.Z Ramos ◽

A.L.D Te-Rosano

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Risk Ratio ◽

Control Strategy ◽

Rate Control ◽

Meta Analysis ◽

Rhythm Control ◽

Forest Plot ◽

Randomized Controlled ◽

All Cause Mortality

Abstract Background Atrial fibrillation (AF) is a common arrhythmia that can promote or worsen heart failure (HF). Limited data exist to guide treatment for patients with AF with HF regarding rate versus rhythm control. Purpose To perform a meta-analysis of randomized controlled trials (RCT) in the determination of the efficacy of rhythm control as compared to rate control among patients with AF and HF. Methods Extensive search of PubMed, Cochrane Library, Ovid, EMBASE, Google scholar, and Medline was done up to October 2020. Studies were limited to RCTs comparing rhythm control in patients with atrial fibrillation and heart failure with rate control. Outcome measures include all-cause mortality and cardiovascular mortality. Statistical analysis was done using Review manager V5.3. Results A total of 9800 patients were included in the pooled analysis of the comparison of rhythm control versus rate control strategy in patients with AF and HF. All pooled analyses were done using random effects model. The pooled risk ratio for all-cause mortality of rate control vs rhythm control did not achieve significance at 1.15, with 95% CI 0.91 to 1.45, and p=0.24. There was statistically significant heterogeneity across the two studies with I2 of 54% and p=0.02 (Figure 1A). The pooled risk ratio for cardiovascular mortality in rate control strategy vs rhythm control is 1.19, with 95% CI 0.94 to 1.50, and p=0.15 (Figure 1B). Eight trials with 9987 participants reported stroke. The pooled risk ratio of stroke in rate control vs rhythm control is 1.11, with 95% CI 0.84 to 1.46, and p=0.47 (Figure 1C). The 95% CI for the pooled risk ratio cross 1.00, indicating an equivocal result. Our results do not indicate statistical heterogeneity across the studies with I2 of 28% and p=0.27. Seven trials with 8311 participants reported bleeding. The pooled risk ratio of hospitalization for bleeding in rate control vs rhythm control is 1.18, with 95% CI 0.81 to 1.73, and p=0.39 (Figure 1D). Thus, we have insufficient evidence to demonstrate whether rate or rhythm control have significantly higher or lower risk for bleeding. Four trials with 8468 participants reported hospitalization rate. The pooled risk ratio of hospitalization in rate control compared to rhythm control is 0.96, with 95% CI 0.86 to 1.07, and p=0.42 (Figure 1E). None of the studies individually showed statistically significant differences but AF–CHF showed benefit of rate control in the first year after enrolment (p=0.001) and a tendency favouring rate control (p=0.06) when the study was analysed in full length except for AF-CHF. Conclusion Among patients with AF and concomitant HF, there is no sufficient evidence between rate and rhythm control strategies in their effects to rates of mortality and major clinical outcomes; therefore, choosing an appropriate therapeutic strategy should consider individual variations such as patient preferences, comorbidities, and treatment cost. FUNDunding Acknowledgement Type of funding sources: None. Forest Plot A–C Forest Plot D–E

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Abstract 15303: The Impact of Heart Rate on the Incidence of Cardiovascular Events in Patients With Chronic Atrial Fibrillation: The Fushimi Af Registry

Circulation ◽

10.1161/circ.132.suppl_3.15303 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Moritake Iguchi ◽

Hisashi Ogawa ◽

Hirofumi Sugiyama ◽

Nobutoyo Masunaga ◽

Mitsuru Ishii ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Heart Rate ◽

Rate Control ◽

Cardiovascular Events ◽

Chronic Atrial Fibrillation ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

The Impact

Purpose: Previous reports suggested that lenient rate control was not inferior to strict rate control among patients with chronic atrial fibrillation (AF). However, the impact of heart rate (HR) on the incidence of cardiovascular events is not clearly understood. Methods: The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients in Fushimi-ku, Kyoto, Japan. At present, follow-up data were available in 3,514 patients (median follow-up period, 842 days). 1,622 patients had chronic AF, and we obtained ECG findings in 1,561 patients. We divided these patients into three groups based on their heart rate; high-HR (HR≥110) (n=179), intermediate-HR (80≤HR<110) (n=695), and low-HR (HR<80) (n=687), and explored the cardiovascular events (composite of cardiovascular death, hospitalization for heart failure, and arrhythmic events). Results: Mean HR was 128±13 bpm, 93±8 bpm, and 67±9 bpm, respectively. High HR group was younger than other groups, but the prevalence of heart failure was the highest (44.7%, 37.0%, 32.3%; p=0.007) and left-ventricular ejection fraction was the lowest (56.5±14.6%, 60.7±11.9%, 62.7±10.5%; p<0.0001). Prescription of beta-blocker (37.4%, 28.9%, 30.0%) and diltiazem (2.8%, 2.9%, 4.2%) was comparable, but prescription of verapamil was the highest in high-HR group (19.0%, 12.4%, 8.0%; p=0.0001), and prescription of digitalis was the highest in low-HR group (14.0%, 18.2%, 23.4%; p=0.005). Mean CHADS2 score was 2.3±1.3, 2.2±1.3, and 2.2±1.4, respectively. In Kaplan-Meier analysis, the incidence of cardiovascular events was higher in high-HR groups than intermediate- and low-HR group (9.2%/year vs 5.8%/year, p=0.02), but was similar between intermediate- and low-HR group (6.2%/year vs 5.4%/year, p=0.3). The incidence of stroke or systemic embolism was comparable between the three groups (2.6%/year, 3.6%/year, 2.4%/year). Cox proportional hazard ratios [95%CI] of high- and intermediate-HR for cardiovascular events compared to low-HR were 1.63 [1.06-2.44] and 1.10 [0.81-1.79], respectively. Conclusions: Among chronic AF patients, the incidence of cardiovascular events was higher in the patients with high-HR, but was similar between intermediate- and low-HR groups.

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