Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study.
OBJECTIVE
The relative risks and benefits of strategies of rate control vs rhythm control in patients with atrial fibrillation (AF) remain to be fully explored.


METHODS
The How to Treat Chronic Atrial Fibrillation (HOT CAFE) Polish trial was designed to evaluate in a randomized, multicenter, and prospective manner the feasibility and long-term outcomes of rate control vs rhythm control strategies in patients with persistent AF.


METHODS
Our study population comprised 205 patients (134 men and 71 women; mean [+/- SD] age, 60.8 +/- 11.2 years) with a mean AF duration of 273.7 +/- 112.4 days. The mean observation period was 1.7 +/- 0.4 years. One hundred one patients were randomly assigned to the rate control group and received rate-slowing therapy guided by repeated 24-h Holter monitoring. Direct current cardioversion and atrioventricular junctional ablation with pacemaker placement were alternative nonpharmacologic strategies for patients with tachycardia that was resistant to medical therapy. One hundred four patients were randomized to sinus rhythm restoration and maintenance using serial cardioversion supported by a predefined stepwise antiarrhythmic drug regimen (ie, disopyramide, propafenone, sotalol, and amiodarone). In both groups, thromboembolic prophylaxis followed current guidelines.


RESULTS
At the end of follow-up, 63.5% of patients in the rhythm control arm remained in sinus rhythm. No significant differences in the composite end point (ie, all-cause mortality, number of thromboembolic events, or major bleeding) were found between the rate control group and the rhythm control group (odds ratio, 1.98; 95% confidence interval, 0.28 to 22.3; p > 0.71). The incidence of hospital admissions was much lower in the rate control arm (12% vs 74%, respectively; p < 0.001). New York Heart Association functional class improved in both study groups, while mean exercise tolerance, as measured by the maximal treadmill workload, improved only in the rhythm control group (5.2 +/- 5.1 vs 7.6 +/- 3.3 metabolic equivalents, respectively; p < 0.001). The rhythm control strategy led to an increased mean left ventricular fractional shortening (29 +/- 7% vs 31 +/- 7%, respectively; p < 0.01). One episode of pulmonary embolism occurred in the rate control group despite oral anticoagulation therapy, while three patients in the rhythm control arm of the study experienced ischemic strokes (not significant).


CONCLUSIONS
The Polish HOT CAFE study revealed no significant differences in major end points between the rate control group and the rhythm control group.
Opolski
Grzegorz
G
Department of Cardiology, Medical University of Warsaw, Warsaw, Poland. grzegorz.opolski@amwaw.edu.pl
Torbicki
Adam
A
Kosior
Dariusz A
DA
Szulc
Marcin
M
Wozakowska-Kaplon
Beata
B
Kolodziej
Piotr
P
Achremczyk
Piotr
P
D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000628:therapy*; D017115:Catheter Ablation; D002908:Chronic Disease; D004452:Echocardiography; D004554:Electric Countershock / Q000379:methods*; D015716:Electrocardiography, Ambulatory; D023381:Endpoint Determination; D017079:Exercise Tolerance; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000209:etiology; D006339:Heart Rate; D006470:Hemorrhage / Q000139:chemically induced; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D011446:Prospective Studies; D013610:Tachycardia / Q000628:therapy
D000889:Anti-Arrhythmia Agents