Corrigendum to: Anticoagulation, therapy of concomitant conditions, and early rhythm control therapy: a detailed analysis of treatment patterns in the EAST-AFNET 4 trial

Background: Even on optimal therapy, many patients with heart failure and atrial fibrillation experience cardiovascular complications. Additional treatments are needed to reduce these events, especially in patients with heart failure and preserved left ventricular ejection fraction (HFpEF). Methods: This prespecified subanalysis of the randomized EAST - AFNET 4 trial assessed the effect of systematic, early rhythm control therapy (ERC; using antiarrhythmic drugs or catheter ablation) compared to usual care (UC, allowing rhythm control therapy to improve symptoms) on the two primary outcomes of the trial and on selected secondary outcomes in patients with heart failure, defined as heart failure symptoms NYHA II-III or left ventricular ejection fraction [LVEF] <50%. Results: This analysis included 798 patients (300 (37.6%) female, median age 71.0 [64.0, 76.0] years, 785 with known LVEF). The majority of patients (n=442) had HFpEF (LVEF≥50%; mean LVEF 61% ± 6.3%), the others had heart failure with mid-range ejection fraction (n=211; LVEF40-49%; mean LVEF 44% ± 2.9%) or heart failure with reduced ejection fraction (n=132; LVEF<40%; mean LVEF 31% ± 5.5%). Over the 5.1-year median follow-up, the composite primary outcome of cardiovascular death, stroke or hospitalization for worsening of heart failure or for acute coronary syndrome occurred less often in patients randomized to ERC (94/396; 5.7 per 100 patient-years) compared with patients randomized to UC (130/402; 7.9 per 100 patient-years; hazard ratio 0.74 [0.56-0.97], p=0.03), not altered by heart failure status (interaction p-value=0.63). The primary safety outcome (death, stroke, or serious adverse events related to rhythm control therapy) occurred in 71/396 (17.9%) heart failure patients randomized to ERC and in 87/402 (21.6%) heart failure patients randomized to UC (hazard ratio 0.85 [0.62-1.17], p=0.33). LV ejection fraction improved in both groups (LVEF change at two years: ERC 5.3%±11.6%, UC 4.9%±11.6%, p=0.43). ERC also improved the composite outcome of death or hospitalization for worsening of heart failure. Conclusions: Rhythm control therapy conveys clinical benefit when initiated within one year of diagnosing atrial fibrillation in patients with signs or symptoms of heart failure. Clinical Trial Registration: Unique Identifiers: ISRCTN04708680, NCT01288352, EudraCT2010-021258-20, Study web site www.easttrial.org; URLs: www.controlled-trials.com; https://clinicaltrials.gov; https://www.clinicaltrialsregister.eu

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Heart Teams in atrial fibrillation

ESC CardioMed ◽

10.1093/med/9780198784906.003.0737 ◽

2018 ◽

pp. 3027-3031

Author(s):

Manuel Castella ◽

Hans-Christoph Diener ◽

Gerhard Hindricks ◽

Paulus Kirchhof

Keyword(s):

Atrial Fibrillation ◽

Organizational Structure ◽

Stroke Prevention ◽

Potential Role ◽

Rhythm Control ◽

Interdisciplinary Teams ◽

Heart Team ◽

Management Decisions ◽

Therapy Options ◽

Control Therapy

Both stroke prevention and rhythm control therapy of atrial fibrillation (AF) have been shaped by interdisciplinary teams of surgeons and cardiologists. This chapter describes the roles of the AF Heart Team in supporting difficult management decisions in AF patients in need of advanced stroke prevention or rhythm control therapy options. It delineates the organizational structure of such AF Heart Teams and provides an outline of their potential role within integrated AF management.

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Vorhofflimmern: Wie wichtig ist der Erhalt des Sinusrhythmus?

DMW - Deutsche Medizinische Wochenschrift ◽

10.1055/a-0969-6352 ◽

2020 ◽

Vol 145 (08) ◽

pp. 543-549

Author(s):

Christian Meyer ◽

Andreas Metzner ◽

Paulus Kirchhof

Keyword(s):

Quality Of Life ◽

Antiarrhythmic Drugs ◽

Pulmonary Veins ◽

Left Ventricular ◽

Rhythm Control ◽

Af Ablation ◽

Stroke Risk Factors ◽

Control Therapy ◽

Rhythm Stability

AbstractRhythm control therapy, comprising antiarrhythmic drugs, cardioversion, and AF ablation, is an important component in the management of patients with atrial fibrillation (AF). Catheter ablation for AF, mainly targeting isolation of the pulmonary veins (AF ablation), has markedly improved the effectiveness of rhythm control therapy. Rhythm control improves symptoms and quality of life in patients with symptomatic AF. AF ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy. Antiarrhythmic drugs remain effective after AF ablation, underpinning the synergistic mechanisms of action of AF ablation and antiarrhythmic drugs. Different lifestyle interventions might additionally improve symptoms and rhythm stability in patients with AF. AF ablation appears to improve left ventricular function in a subset of patients. Summarized, rhythm control therapy in patients with symptomatic AF is safe and improves quality of life, including elderly patients with stroke risk factors. Further studies are needed to determine whether rhythm control therapy reduces AF-related complications while improving patient outcome with regard to prognosis.

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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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Recent advances in rhythm control for atrial fibrillation

F1000Research ◽

10.12688/f1000research.11061.1 ◽

2017 ◽

Vol 6 ◽

pp. 1796 ◽

Cited By ~ 6

Author(s):

Richard Bond ◽

Brian Olshansky ◽

Paulus Kirchhof

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Sinus Rhythm ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Rate Control ◽

Rhythm Control ◽

Management Problem ◽

Recent Trial ◽

Control Therapy

Atrial fibrillation (AF) remains a difficult management problem. The restoration and maintenance of sinus rhythm—rhythm control therapy—can markedly improve symptoms and haemodynamics for patients who have paroxysmal or persistent AF, but some patients fare well with rate control alone. Sinus rhythm can be achieved with anti-arrhythmic drugs or electrical cardioversion, but the maintenance of sinus rhythm without recurrence is more challenging. Catheter ablation of the AF triggers is more effective than anti-arrhythmic drugs at maintaining sinus rhythm. Whilst pulmonary vein isolation is an effective strategy, other ablation targets are being evaluated to improve sinus rhythm maintenance, especially in patients with chronic forms of AF. Previously extensive ablation strategies have been used for patients with persistent AF, but a recent trial has shown that pulmonary vein isolation without additional ablation lesions is associated with outcomes similar to those of more extensive ablation. This has led to an increase in catheter-based technology to achieve durable pulmonary vein isolation. Furthermore, a combination of anti-arrhythmic drugs and catheter ablation seems useful to improve the effectiveness of rhythm control therapy. Two large ongoing trials evaluate whether a modern rhythm control therapy can improve prognosis in patients with AF.

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Atrial fibrillation in congestive heart failure: is rhythm control therapy superior to rate control therapy?

Journal of Cardiac Failure ◽

10.1016/s1071-9164(03)00436-6 ◽

2003 ◽

Vol 9 (5) ◽

pp. S55

Author(s):

Sana M. Al-Khatib ◽

Linda Shaw ◽

Monica Shah ◽

Chris O'Connor ◽

Robert M. Califf

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Congestive Heart Failure ◽

Rate Control ◽

Rhythm Control ◽

Control Therapy

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Rate versus rhythm control therapy for atrial fibrillation

10.1093/med/9780198784906.003.0511 ◽

2018 ◽

Author(s):

Albert L. Waldo

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Control Strategy ◽

Rate Control ◽

Anticoagulation Therapy ◽

Rhythm Control ◽

Rate Versus ◽

Ventricular Response ◽

Tachycardia Induced Cardiomyopathy ◽

Stable Sinus Rhythm

Based on data from several clinical trials, either rate control or rhythm control is an acceptable primary therapeutic strategy for patients with atrial fibrillation. However, since atrial fibrillation tends to recur no matter the therapy, rate control should almost always be a part of the treatment. If a rhythm control strategy is selected, it is important to recognize that recurrence of atrial fibrillation is common, but not clinical failure per se. Rather, the frequency and duration of episodes, as well as severity of symptoms during atrial fibrillation episodes should guide treatment decisions. Thus, occasional recurrence of atrial fibrillation despite therapy may well be clinically acceptable. However, for some patients, rhythm control may be the only strategy that is acceptable. In short, for most patients, either a rate or rhythm control strategy should be considered. However, for all patients, there are two main goals of therapy. One is to avoid stroke and/or systemic embolism, and the other is to avoid a tachycardia-induced cardiomyopathy. Also, because of the frequency of atrial fibrillation recurrence despite the treatment strategy selected, patients with stroke risks should receive anticoagulation therapy despite seemingly having achieved stable sinus rhythm. For patients in whom a rate control strategy is selected, a lenient approach to the acceptable ventricular response rate is a resting heart rate of 110 bpm, and probably 90 bpm. The importance of achieving and maintaining sinus rhythm in patients with atrial fibrillation and heart failure remains to be clearly established.

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Atrial fibrillation

10.1093/med/9780199685288.003.1152_update_004 ◽

2016 ◽

Author(s):

Demosthenes G. Katritsis ◽

Bernard J. Gersh ◽

A. John Camm

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Rhythm Control ◽

New Drugs ◽

Control Therapy

Classification, epidemiology, aetiology, and the pathophysiological consequences of atrial fibrillation are discussed. Rate and rhythm control therapy, anticoagulation with warfarin and new drugs, and current indications of catheter ablation are presented. ACC/AHA and ESC recommendations have been summarized and tabulated.

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