title: Rate versus rhythm control and outcomes in patients with atrial fibrillation and chronic kidney disease: data from the GUSTO-III Trial.
abstract: BACKGROUND
  Atrial fibrillation (AF) and chronic kidney disease (CKD) have both been shown to portend worse outcomes after acute myocardial infarction (MI); however, the benefit of a rhythm control strategy in patients with CKD post-MI is unclear.
  
  
  METHODS
  We prospectively studied 985 patients with new-onset AF post-MI in the GUSTO-III trial, of whom 413 (42%) had CKD (creatinine clearance < 60 mL/min). A rhythm control strategy, defined as the use of an antiarrhythmic medication and/or electrical cardioversion, was used in 346 (35%) of patients.
  
  
  RESULTS
  A rhythm control strategy was used in 34% of patients with CKD and 36% of patients with no CKD. At hospital discharge, sinus rhythm was present in 487 (76%) of patients treated with a rate control strategy, vs. 276 (80%) in those treated with rhythm control (p = 0.20). CKD was associated with a lower odds of sinus rhythm at discharge (unadjusted OR 0.56, 95% CI 0.38-0.84, p < 0.001). However, in multivariable analyses, treatment with a rhythm control strategy was not associated with discharge rhythm (HR 1.068, 95% CI 0.69-1.66, p = 0.77), 30-day mortality (HR 0.78, 95% CI 0.54-1.12, p = 0.18) or mortality from day 30 to 1 year (HR 1.00, 95% CI 0.59-1.69, p = 0.99). CKD status did not significantly impact the relationship between rhythm control and outcomes.
  
  
  CONCLUSIONS
  Treatment with a rhythm or rate control strategy does not signifi cantly impact short-term or long-term mortality in patients with post-MI AF, regardless of kidney disease status. Future studies to investigate the optimal management of AF in CKD patients are needed.
authors.affiliation: Division of Cardiology, University of Washington Medical Center, Seattle, WA, USA. alkha001@mc.duke.edu.
authors.forename: Eric S
authors.initials: ES
authors.lastname: Williams
authors.forename: Vivian P
authors.initials: VP
authors.lastname: Thompson
authors.forename: Karen E
authors.initials: KE
authors.lastname: Chiswell
authors.forename: John H
authors.initials: JH
authors.lastname: Alexander
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.forename: Sana M
authors.initials: SM
authors.lastname: Al-Khatib
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000889:Anti-Arrhythmia Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D016009:Chi-Square Distribution; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D004554:Electric Countershock / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006339:Heart Rate / Q000187:drug effects*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D016017:Odds Ratio; D010351:Patient Discharge; D016016:Proportional Hazards Models; D011446:Prospective Studies; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000889:Anti-Arrhythmia Agents