title: Comparison of rate versus rhythm control in patients with atrial fibrillation and a pacemaker.
abstract: The effect of rate versus rhythm control in patients with atrial fibrillation who have undergone previous pacemaker (PM) implantation is unknown. We evaluated the mortality in patients with atrial fibrillation and a PM randomized to rate or rhythm control treatment strategies. The Atrial Fibrillation Follow-up Investigation of Rhythm Management data set was stratified by the presence (n = 250) or absence (n = 3,810) of a PM at randomization into the rate or rhythm control arm. Kaplan-Meier curves were used for univariate analysis, and proportional hazards were used for multivariate analysis. The subjects with a PM (n = 250) were older (73 vs 69 years, p <0.01) and had a greater prevalence of coronary artery disease (53% vs 37%, p <0.01) and congestive heart failure (33% vs 23%, p <0.01). All-cause mortality was significantly greater in the PM patients who were randomized to the rhythm control arm (n = 128) than in the patients enrolled in the rate control arm with or without a PM (n = 2,027, p <0.01) and those in the rhythm control arm without a PM (n = 1,905, p <0.01). Multivariate analysis revealed that predictors of all-cause mortality included PM patients randomized to the rhythm control arm (hazard ratio 2.59, 95% confidence interval 1.46 to 4.58, p <0.01) and the presence of congestive heart failure (hazard ratio 2.42, 95% confidence interval 1.40 to 4.16, p <0.01). In conclusion, all-cause mortality was greater among patients with atrial fibrillation with a PM, who were randomized to the rhythm control arm of the Atrial Fibrillation Follow-up Investigation of Rhythm Management study compared with all other patients enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management study. The rhythm control strategy in patients with a PM was an independent predictor of mortality.
authors.affiliation: Division of Cardiology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
authors.forename: Apurva Omkar
authors.initials: AO
authors.lastname: Badheka
authors.forename: George Robert
authors.initials: GR
authors.lastname: Marzouka
authors.forename: Ankit Dineshbhai
authors.initials: AD
authors.lastname: Rathod
authors.forename: Nileshkumar Jasmatbhai
authors.initials: NJ
authors.lastname: Patel
authors.forename: Robert Jerome
authors.initials: RJ
authors.lastname: Myerburg
authors.forename: Raul David
authors.initials: RD
authors.lastname: Mitrani
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D000369:Aged, 80 and over; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000209:etiology / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy*; D002121:Calcium Channel Blockers / Q000627:therapeutic use*; D003324:Coronary Artery Disease / Q000150:complications; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000503:physiopathology; D006333:Heart Failure / Q000150:complications; D006339:Heart Rate / Q000187:drug effects*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D010138:Pacemaker, Artificial; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States; D054556:Venous Thromboembolism / Q000517:prevention & control
chemical_list: D000319:Adrenergic beta-Antagonists; D000889:Anti-Arrhythmia Agents; D002121:Calcium Channel Blockers