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

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.

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

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
R Mo ◽  
Y Yang ◽  
L Yu
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Adverse Events ◽  
Rate Control ◽  
Cardiovascular Death ◽  
Control Treatment ◽  
All Cause Mortality ◽  
One Year ◽  
Cox Analysis ◽  
The Impact

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

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

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.

scholarly journals Sex differences in treatment strategy and adverse outcomes among patients 75 and older with atrial fibrillation in the MarketScan database

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Vinita Subramanya ◽  
J’Neka S. Claxton ◽  
Pamela L. Lutsey ◽  
Richard F. MacLehose ◽  
Lin Y. Chen ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Sex Differences ◽  
Rate Control ◽  
Treatment Strategy ◽  
Cox Regression ◽  
Rhythm Control ◽  
Adverse Outcomes ◽  
Control Treatment ◽  
To Receive

Abstract Background Women with atrial fibrillation (AF) experience greater symptomatology, worse quality of life, and have a higher risk of stroke as compared to men, but are less likely to receive rhythm control treatment. Whether these differences exist in elderly patients with AF, and whether sex modifies the effectiveness of rhythm versus rate control therapy has not been assessed. Methods We studied 135,850 men and 139,767 women aged ≥ 75 years diagnosed with AF in the MarketScan Medicare database between 2007 and 2015. Anticoagulant use was defined as use of warfarin or a direct oral anticoagulant. Rate control was defined as use of rate control medication or atrioventricular node ablation. Rhythm control was defined by use of anti-arrhythmic medication, catheter ablation or cardioversion. We used multivariable Poisson and Cox regression models to estimate the association of sex with treatment strategy and to determine whether the association of treatment strategy with adverse outcomes (bleeding, heart failure and stroke) differed by sex. Results At the time of AF, women were on average (SD) 83.8 (5.6) years old and men 82.5 (5.2) years, respectively. Compared to men, women were less likely to receive an anticoagulant or rhythm control treatment. Rhythm control (vs. rate) was associated with a greater risk for heart failure with a significantly stronger association in women (HR women = 1.41, 95% CI 1.34–1.49; HR men = 1.21, 95% CI 1.15–1.28, p < 0.0001 for interaction). No sex differences were observed for the association of treatment strategy with the risk of bleeding or stroke. Conclusion Sex differences exist in the treatment of AF among patients aged 75 years and older. Women are less likely to receive an anticoagulant and rhythm control treatment. Women were also at a greater risk of experiencing heart failure as compared to men, when treated with rhythm control strategies for AF. Efforts are needed to enhance use AF therapies among women. Future studies will need to delve into the mechanisms underlying these differences.

scholarly journals Sex Differences in Treatment Strategy and Adverse Outcomes Among Patients 75 and Older With Atrial Fibrillation in the MarketScan Database

2021 ◽  
Author(s):  
Vinita Subramanya ◽  
J’Neka S. Claxton ◽  
Pamela L. Lutsey ◽  
Richard F. MacLehose ◽  
Lin Y. Chen ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Sex Differences ◽  
Rate Control ◽  
Treatment Strategy ◽  
Cox Regression ◽  
Rhythm Control ◽  
Adverse Outcomes ◽  
Control Treatment ◽  
To Receive

Abstract Background: Women with atrial fibrillation (AF) experience greater symptomatology, worse quality of life, and have a higher risk of stroke as compared to men, but are less likely to receive rhythm control treatment. Whether these differences exist in elderly patients with AF, and whether sex modifies the effectiveness of rhythm versus rate control therapy has not been assessed.Methods: We studied 135,850 men and 139,767 women aged ≥75 years diagnosed with AF in the MarketScan Medicare database between 2007-2015. Anticoagulant use was defined as use of warfarin or a direct oral anticoagulant. Rate control was defined as use of rate control medication or atrioventricular node ablation. Rhythm control was defined by use of anti-arrhythmic medication, catheter ablation or cardioversion. We used multivariable Poisson and Cox regression models to estimate the association of sex with treatment strategy and to determine whether the association of treatment strategy with adverse outcomes (bleeding, heart failure and stroke) differed by sex. Results: At the time of AF, women were on average (SD) 83.8 (5.6) years old and men 82.5 (5.2) years, respectively. Compared to men, women were less likely to receive an anticoagulant or rhythm control treatment. Rhythm control (vs. rate) was associated with a greater risk for heart failure with a significantly stronger association in women (HR women = 1.41, 95%CI 1.34-1.49; HR men= 1.21, 95%CI 1.15-1.28, p <0.0001 for interaction). No sex differences were observed for the association of treatment strategy with the risk of bleeding or stroke. Conclusion: Sex differences exist in the treatment of AF among patients aged 75 years and older. Women are less likely to receive an anticoagulant and rhythm control treatment. Women were also at a greater risk of experiencing heart failure as compared to men, when treated with rhythm control strategies for AF. Efforts are needed to enhance use AF therapies among women. Future studies will need to delve into the mechanisms underlying these differences.

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

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

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

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

scholarly journals A genetic model of ivabradine recapitulates results from randomized clinical trials

2020 ◽  
Author(s):  
Marc-André Legault ◽  
Johanna Sandoval ◽  
Sylvie Provost ◽  
Amina Barhdadi ◽  
Louis-Philippe Lemieux Perreault ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Atrial Fibrillation ◽  
Heart Rate ◽  
Drug Target ◽  
Drug Targets ◽  
Risk Model ◽  
Cardiovascular Death ◽  
Increased Risk ◽  
The Uk

ABSTRACTBackgroundNaturally occurring human genetic variants provide a valuable tool to identify drug targets and guide drug prioritization and clinical trial design. Ivabradine is a heart rate lowering drug with protective effects on heart failure despite increasing the risk of atrial fibrillation. In patients with coronary artery disease without heart failure, the drug does not protect against major cardiovascular adverse events prompting questions about the ability of genetics to have predicted those effects. This study evaluates the effect of a mutation in HCN4, ivabradine’s drug target, on safety and efficacy endpoints.MethodsWe used genetic association testing and Mendelian randomization to predict the effect of ivabradine and heart rate lowering on cardiovascular outcomes.ResultsUsing data from the UK Biobank and large GWAS consortia, we evaluated the effect of a heart rate-reducing genetic variant at the HCN4 locus encoding ivabradine’s drug target. These genetic association analyses showed increases in risk for atrial fibrillation (OR 1.09, 95% CI: 1.06-1.13, P=9.3 ×10−9) in the UK Biobank. In a cause-specific competing risk model to account for the increased risk of atrial fibrillation, the HCN4 variant reduced incident heart failure in participants that did not develop atrial fibrillation (HR 0.90, 95% CI: 0.83-0.98, P=0.013). In contrast, the same heart rate reducing HCN4 variant did not prevent a composite endpoint of myocardial infarction or cardiovascular death (OR 0.99, 95% CI: 0.93-1.04, P=0.61).ConclusionGenetic modelling of ivabradine recapitulates its benefits in heart failure, promotion of atrial fibrillation, and neutral effect on myocardial infarction.CONDENSED ABSTRACTThe effects of drugs can sometimes be predicted from the effects of mutations in genes encoding drug targets. We tested the effect of a heart rate reducing allele at the HCN4 locus encoding ivabradine’s drug target and found results coherent with the SHIFT and SIGNIFY clinical trials of ivabradine. The genetic variant increased the risk of atrial fibrillation and cardioembolic stroke and protected against heart failure in a competing risk model accounting for the increased risk of atrial fibrillation. The variant had a neutral effect on a composite of myocardial infarction and cardiovascular death.

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