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

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.

Rhythm Control in Patients with Heart Failure with Preserved Ejection Fraction: A Meta-Analysis

Background The presence of atrial fibrillation (AF) in patients with heart failure with preserved ejection fraction (HFpEF) dramatically increases higher morbidity and mortality. Recent studies have suggested that early rhythm control may alleviate the burden of poor outcomes. Currently, there remain limited data on whether rhythm or rate control has better efficacy. This study sought to compare both strategies in HFpEF patients with AF. Methods Databases were searched throughout 2020. Studies that reported cardiovascular outcomes amongst HFpEF patients with AF who received either rhythm or rate control were included. Estimates of the effects from the individual studies were extracted and combined using random-effects, a generic inverse variance method of DerSimonian and Laird. Results Five observational studies were included in the analysis, consisting of 16,953 patients, 13.8% of whom were receiving rhythm control. In comparison with rate control, rhythm control was associated with decreased overall mortality rates (pooled RR 0.85, 95% CI 0.75–0.95, with I2 = 0%, p value = 0.009). Conclusions In HFpEF patients with AF, rhythm control was associated with lower mortality, compared to rate control. Further studies are warranted to validate our observation.

The Effects of Controlled Tempo Manipulations on Cardiovascular Autonomic Function

Music has been associated with alterations in autonomic function. Tempo, the speed of music, is one of many musical parameters that may drive autonomic modulation. However, direct measures of sympathetic nervous system activity and control groups and/or control stimuli do not feature in prior work. This article therefore reports an investigation into the autonomic effects of increases and decreases in tempo. Fifty-eight healthy participants (age range: 22–80 years) were randomly allocated to either an experimental ( n = 29, tune) or control (rhythm of the same tune) group. All participants underwent five conditions: baseline, stable tempo (tune/rhythm repeatedly played at 120 bpm), tempo increase (tune/rhythm played at 60 bpm, 90 bpm, 120 bpm, 150 bpm, 180 bpm), tempo decrease (tune/rhythm played at 180 bpm, 150 bpm, 120 bpm, 90 bpm, 60 bpm) and recovery. Heart rate, blood pressure, respiration, and muscle sympathetic nerve activity were continuously recorded. The 60 bpm in the tempo decrease stimulus was associated with increases in measures of parasympathetic activity. The 180 bpm in the tempo increase stimulus was also associated with shifts towards parasympathetic predominance. Responses to the stimuli were predicted by baseline %LF. It is concluded that the individual tempi impacted upon autonomic function, despite the entire stimulus having little effect. The 60 bpm in an increasingly slower stimulus was associated with greater vagal modulations of heart rate than faster tempi. For the first time, this study shows that response direction and magnitude to tempo manipulations were predicted by resting values, suggesting that music responders may be autonomically distinct from non-responders.

Rate Control vs. Rhythm Control for Atrial Fibrillation

This case focuses on how to maintain cardiac rhythm in older patients with arterial fibrillation and cardiovascular risks by asking the question: Should patients with atrial fibrillation be managed with a strategy of rate control or rhythm control? In high-risk patients with atrial fibrillation, a strategy of rate control is at least as effective as a strategy of rhythm control. Rhythm control does not appear to obviate the need for anticoagulation. Because the medications used for rate control are usually safer than those used for rhythm control, rate control is the preferred strategy for treating most high-risk patients with atrial fibrillation. These findings do not necessarily apply to younger patients without cardiovascular risk factors who were not included in AFFIRM, however.

Abstract 18974: Rhythm Control with Catheter Ablation Improves Cardiomyopathy and Heart Failure Compared with Rate Control

Introduction: Role of rhythm control in addition to rate control, in patients with atrial fibrillation and heart failure reduced EF (HFrEF) is unknown. Objective: We sought to compare catheter ablation with rate control in patients with AF and HFrEF. Methods: Ninety patients with AF and LVEF < 40 % underwent pulmonary vein isolation with or without substrate modification. Follow-up included Holter monitoring and echocardiography at baseline, 3 months and at 6 months. A propensity-matched group of 80 patients with AF and LVEF <40% treated with rate control was used for comparison. Post-matching weighted linear regression analysis was used to compare outcomes. Results: At 6 months, 64% of patients who underwent ablation remained in sinus rhythm. Average heart rate (HR) was similar between groups at baseline and follow up. (79 ± 14.5 to 76 ± 7.7 in ablation group and 82.4 ±8.9 to 78.3 ± 8.8 in rate control group). LVEF significantly improved in patients who underwent ablation (30.9 ± 8.6 to 43.4 ±10.9) compared with no change in patients who were rate controlled (to 25.8 ±19.3 to 25.2 ±6.64) (p=2E-16). NHYA class improved from 2.26 ±0.44 to 1.62 ±0.64 with ablation compared to 2.4 ±0.5 to 2.24 ±0.44 with rate control but did not reach statistical significance. Patients who remained in AF after ablation had minimal change in LVEF and NHYA class. No procedural complications noted. Conclusions: In patients with AF, HFrEF, and adequate HR control, rhythm control by catheter ablation improved LVEF compared with a propensity matched group of patients treated with rate control. Rhythm control with catheter ablation may be considered in patients with AF and HF who are adequately rate controlled