Abstract

OBJECTIVES: The study sought to evaluate clinical outcomes in clinical practice with rhythm control versus rate control strategy for management of atrial fibrillation (AF).BACKGROUND: Randomized trials have not demonstrated significant differences in stroke, heart failure, or mortality between rhythm and rate control strategies. The comparative outcomes in contemporary clinical practice are not well described.METHODS: Patients managed with a rhythm control strategy targeting maintenance of sinus rhythm were retrospectively compared with a strategy of rate control alone in a AF registry across various U.S. practice settings. Unadjusted and adjusted (inverse-propensity weighted) outcomes were estimated.RESULTS: The overall study population (N= 6,988) had a median of 74 (65 to 81) years of age, 56% were males, 77% had first detected or paroxysmal AF, and 68% had CHADS2 score=2. In unadjusted analyses, rhythm control was associated with lower all-cause death, cardiovascular death, first stroke/non-central nervous system systemic embolization/transient ischemic attack, or first major bleeding event (all p< 0.05); no difference in new onset heart failure (p=0.28); and more frequent cardiovascular hospitalizations (p= 0.0006). There was no difference in the incidence of pacemaker, defibrillator, or cardiac resynchronization device implantations (p= 0.99). In adjusted analyses, there were no statistical differences in clinical outcomes between rhythm control and rate control treated patients (all p > 0.05); however, rhythm control was associated with more cardiovascular hospitalizations (hazard ratio: 1.24; 95% confidence interval: 1.10 to 1.39; p= 0.0003).CONCLUSIONS: Among patients with AF, rhythm control was not superior to rate control strategy for outcomes of stroke, heart failure, or mortality, but was associated with more cardiovascular hospitalizations.

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