Interesting news from the heart front. Studies now show that trying to keep someone in a normal, sinus
rhythm (if you have something called atrial fibrillation, or, in the lingo, “A-Fib”) doesn’t help. In fact, it’s probably BAD. A-fib is an irregular, syncopated heart rhythm caused when the atria suddenly decide to rumba. Doctors, and especially cardiologists, have struggled mightily to get people back to the more mundane, suburban ta-dum, ta-dum, ta-dum beat that most of us march to. What other option is there? The alternative is to just let you stay in A-fib, but give you drugs to make sure you don’t get carried away and go too fast – no snazzy drum solos for your heart, no sirree. These two different approaches (changing the rhythm, versus controlling the rate) can also be thought of as new school versus old-school approaches. The two were compared head-to-head (heart-to-heart?) and guess who won? The old-fashioned rate approach. In other words, keep dancing the rumba, just don’t go too fast. This held true, even in folks with severe heart failure. Which just goes to show, everything old is new again. For rhythm geeks wanting more details (especially if you have trouble accessing this For Doctors Eyes Only article link), check it out here:
Here’s the Heartwire low-down:
“Previous research has suggested that rate control is superior to rhythm control in the treatment of patients with atrial fibrillation who have a high risk for stroke or death. In a study by Wyse and colleagues, which was published in the December 5, 2002, issue of the New England Journal of Medicine, 4060 patients with atrial fibrillation were randomized to a strategy of rate control vs rhythm control. The rhythm-control treatment strategy was associated with a 15% relative increase in the risk for death, an increased risk for hospitalization, and adverse drug events vs the rate-control strategy.
The current study by Roy and colleagues again compares the treatment strategies of rate control vs rhythm control for atrial fibrillation. This trial focuses specifically on patients with significant heart failure.
AF/CHF, a prospective, open-label, multicenter trial, enrolled patients with left ventricular ejection fraction (LVEF) of 35% or less and symptoms of CHF (NYHA [New York Heart Association] class 2-4). Asymptomatic patients could be enrolled, however, if they had a prior hospitalization for CHF or an LVEF ≤25%. In addition to the CHF criteria, patients had to have a history of significant AF — defined as either one episode lasting more than six hours within the past six months or one episode of shorter duration but with prior electrical cardioversion.
The 1376 patients were randomly allocated to rhythm or rate control between May 2001 and June 2005 at 123 sites in North America, South America, and Europe, with a minimum follow-up of two years. More than two-thirds of patients were enrolled having a persistent type of AF, and more than 50% had been previously hospitalized for AF or CHF…Intention-to-treat analysis revealed no difference in the primary end point between the two groups. Cardiovascular death occurred in 182 (26.7%) of the patients in the rhythm-control group compared with 175 (25.2%) in the rate-control arm (hazard ratio 1.058, p=0.59).
Total mortality, worsening CHF, and stroke were similar between the two groups, as was the composite end point of cardiovascular death, worsening CHF, and stroke. Cardiovascular mortality was also similar between the two arms in a number of prespecified subgroups.
During the course of the study, 21% of patients crossed over from rhythm to rate control, primarily because of the inability to maintain sinus rhythm. Meanwhile 10% crossed from the rate-control arm to rhythm control, primarily because of worsening heart failure.
Hospitalization was higher in the rhythm group (46% vs 39% in the rate group at one year; p=0.0063), mainly due to hospitalization for AF and bradyarrhythmias (8.5% vs 4.9%, p=0.0074), Roy said. As expected, cardioversions were also much higher in the rhythm-control group (39% vs 8%).
‘We could not demonstrate any benefit with the more complex rhythm strategy, so adequate rate control may be sufficient and appropriate in these patients.'”
Summary: “Rate control is just as good as rhythm control for patients with CHF and AF. Outcomes of total mortality, worsening CHF, and stroke were similar between the 2 groups, as was the composite endpoint of cardiovascular death, worsening CHF, and stroke. A routine strategy of rhythm control therefore cannot be recommended in patients with CHF and AF.”