Clinical factors that influence response to treatment strategies in atrial fibrillation: the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study.
BACKGROUND
The AFFIRM Study was a randomized multicenter comparison of 2 treatment strategies, rate-control versus rhythm-control, in high-risk patients with atrial fibrillation (AF). The primary outcome of the trial showed no overall difference in survival between strategies. However, there may be important patient subgroups for which there are identifiable differences in outcome with 1 of the 2 strategies.


RESULTS
Subgroups that were prespecified for analysis from the main AFFIRM Study were age, sex, coronary artery disease (CAD), hypertension, congestive heart failure (CHF), left ventricular ejection fraction (LVEF), rhythm at randomization, first episode of AF, and duration of the qualifying episode of AF. Baseline characteristics were analyzed for each subgroup. Adjusted hazard ratios for each subgroup and for each stratum were generated using Cox models, and these models were used to determine whether treatment strategy affected overall survival differentially by subgroup. Adjusted survival was worse for patients > or =65 years and for patients with a history of CHF, CAD, or an abnormal LVEF. In the adjusted analyses, the effect of treatment strategy was similar within all of the prespecified subgroups. When each subgroup stratum was analyzed separately, patients > or =65 years and patients without a history of CHF had significantly better outcome with rate-control therapy (each P < .01).


CONCLUSIONS
Overall, treatment effect for rate control versus rhythm control was the same within each subgroup. However, certain selected patient categories may have better survival with one particular strategy for management of AF.
Curtis
Anne B
AB
University of Florida, Box 100277, 1600 SW Archer Rd, Gainesville, FL 32610, USA. curtisa@medicine.ufl.edu
Gersh
Bernard J
BJ
Corley
Scott D
SD
DiMarco
John P
JP
Domanski
Michael J
MJ
Geller
Nancy
N
Greene
H Leon
HL
Kellen
Joyce C
JC
Mickel
Mary
M
Nelson
Joy Dalquist
JD
Rosenberg
Yves
Y
Schron
Eleanor
E
Shemanski
Lynn
L
Waldo
Albert L
AL
Wyse
D George
DG
D000367:Age Factors; D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology / Q000601:surgery / Q000628:therapy; D003131:Combined Modality Therapy; D003327:Coronary Disease / Q000150:complications; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000187:drug effects / Q000503:physiopathology; D006333:Heart Failure / Q000150:complications; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D006973:Hypertension / Q000150:complications; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012307:Risk Factors; D012737:Sex Factors; D013318:Stroke Volume; D016019:Survival Analysis; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000150:complications
D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants