Rhythm control versus rate control for atrial fibrillation and heart failure.
BACKGROUND
It is common practice to restore and maintain sinus rhythm in patients with atrial fibrillation and heart failure. This approach is based in part on data indicating that atrial fibrillation is a predictor of death in patients with heart failure and suggesting that the suppression of atrial fibrillation may favorably affect the outcome. However, the benefits and risks of this approach have not been adequately studied.


METHODS
We conducted a multicenter, randomized trial comparing the maintenance of sinus rhythm (rhythm control) with control of the ventricular rate (rate control) in patients with a left ventricular ejection fraction of 35% or less, symptoms of congestive heart failure, and a history of atrial fibrillation. The primary outcome was the time to death from cardiovascular causes.


RESULTS
A total of 1376 patients were enrolled (682 in the rhythm-control group and 694 in the rate-control group) and were followed for a mean of 37 months. Of these patients, 182 (27%) in the rhythm-control group died from cardiovascular causes, as compared with 175 (25%) in the rate-control group (hazard ratio in the rhythm-control group, 1.06; 95% confidence interval, 0.86 to 1.30; P=0.59 by the log-rank test). Secondary outcomes were similar in the two groups, including death from any cause (32% in the rhythm-control group and 33% in the rate-control group), stroke (3% and 4%, respectively), worsening heart failure (28% and 31%), and the composite of death from cardiovascular causes, stroke, or worsening heart failure (43% and 46%). There were also no significant differences favoring either strategy in any predefined subgroup.


CONCLUSIONS
In patients with atrial fibrillation and congestive heart failure, a routine strategy of rhythm control does not reduce the rate of death from cardiovascular causes, as compared with a rate-control strategy. (ClinicalTrials.gov number, NCT00597077.)
Montreal Heart Institute and the Université de Montréal, Montreal, QC H1T 1C8, Canada. d_roy@icm-mhi.com
Denis
D
Roy
Mario
M
Talajic
Stanley
S
Nattel
D George
DG
Wyse
Paul
P
Dorian
Kerry L
KL
Lee
Martial G
MG
Bourassa
J Malcolm O
JM
Arnold
Alfred E
AE
Buxton
A John
AJ
Camm
Stuart J
SJ
Connolly
Marc
M
Dubuc
Anique
A
Ducharme
Peter G
PG
Guerra
Stefan H
SH
Hohnloser
Jean
J
Lambert
Jean-Yves
JY
Le Heuzey
Gilles
G
O'Hara
Ole Dyg
OD
Pedersen
Jean-Lucien
JL
Rouleau
Bramah N
BN
Singh
Lynne Warner
LW
Stevenson
William G
WG
Stevenson
Bernard
B
Thibault
Albert L
AL
Waldo
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D000638:Amiodarone / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000517:prevention & control*; D002318:Cardiovascular Diseases / Q000401:mortality; D003131:Combined Modality Therapy; D004071:Digitalis Glycosides / Q000627:therapeutic use; D004554:Electric Countershock; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000150:complications / Q000188:drug therapy / Q000628:therapy*; D006339:Heart Rate; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018487:Ventricular Dysfunction, Left
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000889:Anti-Arrhythmia Agents; D004071:Digitalis Glycosides; D000638:Amiodarone