Atrial Fibrillation: Rate vs. Rhythm Michael Curley, MD Cardiac Electrophysiology
I have no relevant financial disclosures pertaining to this topic.
A Fib Epidemiology #1 Most common heart rhythm disturbance Circulation 2004;110:1042 1046
A Fib Epidemiology 1 in 4 Americans over 40 will be diagnosed Circulation 2004;110:1042 1046
A Fib Epidemiology 3.5 million to 6.1 million Number of Americans who have A fib JACC 2016;68.5: 525-568
A Fib Epidemiology $6,000,000,000 Annual expenditure in US on A fib care www.cdc.gov/dhdsp/data_stastistics/fact_sheet/fs_atrial_fibrillation.htm
A Fib Epidemiology!"#$% 9$% 2,, &%'()('*+,-./(01.23."%,4.5#(,,("%-6 : ; < = >? @ A?AA<?A@A?A@<?A?A?A?<?A>A?A><?A=A?A=< 7$+8?A<A JACC 2016;68.5: 525-568; Am J Cardiol 2009;104:1534 1539
Impact of A Fib Markedly reduces quality of life Increases risk of stroke Increases risk of developing heart failure Increases likelihood of hospitalization Increases risk of mortality J Am Coll Cardiol 2000;36:1303 1309 ArchIntern Med1987;147:1561 1564 Am J Cardiol 1998;82:2N 9N Circ Cardiovasc Qual Outcomes 2011;4:313 4320
Impact of A Fib JAMA Neurol. 2015;72(11):1288-1294
Impact of A Fib Individuals with AF are 2 times more likely to develop dementia than those without AF JAMA Neurol. 2015;72(11):1288-1294
Principle Goals of A Fib Management 1. Symptom Control 2. Stroke prophylaxis Image from: www.health.harvard.edu/staying-healthy/step-lively-with-walking
Definitions Rate control A strategy employing the use of AV nodal blocking agents such as beta blocks, calcium channel blockers or digoxin. AV nodal ablation plus ventricular pacing
Definitions Rhythm control A strategy employing antiarrhythmic drug therapy, catheter ablation (radiofrequency, cryoablation, laser) and/or a surgical procedure to maintain sinus rhythm.
Definitions Rhythm control A strategy employing antiarrhythmic drug therapy, catheter ablation (radiofrequency, cryoablation, laser) and/or a surgical procedure to maintain sinus rhythm.
Trial Data RACE Trial AFFIRM Trial N Engl J Med 2002;347:1825-33 N Engl J Med 2002;347:1834-40
AFFIRM Design: multi-center, prospective, randomized, controlled Subjects: 4060 patients Inclusion criteria: AF, 65 years + (mean age 70) Primary endpoint: all-cause mortality N Engl J Med 2002;347:1825-33
AFFIRM Rate control group: HR <80 at rest, <110 during 6 minute walk test Rhythm control group: amiodarone, disopyramide, flecainide, propafenone, quinidine, sotalol, dofetilide or any combination. If 2+ drugs failed, ablation was deemed acceptable. N Engl J Med 2002;347:1825-33
AFFIRM N Engl J Med 2002;347:1825-33
AFFIRM Trend towards increased primary endpoint in rhythm group No difference in global functional status or quality of life Increased risk of hospitalization in the rhythm control group N Engl J Med 2002;347:1825-33
RACE Design: multi-center, prospective, randomized, controlled Subjects: 522 patients (mean 68 years of age) Inclusion criteria: persistent AF or atrial flutter, 1-2 prior DCCVs Primary endpoint: Composite of cardiovascular death, HF, thromboembolism, pacemaker implantation, or severe adverse drug effect N Engl J Med 2002;347:1825-33
RACE Rate control group: HR <100 Rhythm control group: sotalol initially; flecainide, propafenone or amiodarone used if arrhythmia recurrence within 6 months N Engl J Med 2002;347:1834-1840
RACE N Engl J Med 2002;347:1834-1840
RACE Trend towards increased primary endpoint in rhythm group No difference in cardiovascular mortality No difference in quality of life Increased risk of heart failure, thromboembolism, pacemaker insertion and adverse drug reactions N Engl J Med 2002;347:1834-1840
Limitations of AFFIRM and RACE Young, healthy patients not enrolled Approximately 50% of AFFIRM patients with symptomatic AF had symptomatic episodes less than once per month Data were gathered largely before the wide spread utilization of pulmonary vein isolation Both trials allowed for cessation of anticoagulant therapy 4 weeks after restoration of sinus rhythm Arch Intern Med 2012;172:172-983
ORBIT-AF Design: multi-center, retrospective, registry dataset Subjects: 6,988 patients Inclusion criteria: age >18, AF of any variety Study outcomes: all-cause death, cardiovascular death, first stroke/tia, new onset heart failure and major bleeding JACC EP 2016;2:221 229
ORBIT-AF Take away: Rhythm control was not superior to rate control strategy for outcomes of stroke, heart failure, or mortality, but was associated with more cardiovascular hospitalizations. JACC EP 2016;2:221 229
Is There a Role for Rhythm Control? Young patients Patients early in their natural history - Reversible etiology: hyperthyroidism, PE, pericarditis - Normal left atrial size Individuals who are symptomatic despite rate control Inability to adequately attain rate control
Take Home Points The clinical and economic burden of AF is large and will continue to increase in the coming decades. Impact is wide ranging: heart failure, stroke, dementia, etc. Randomized and observation data have failed to demonstrate benefit of rhythm control strategy on mortality, stroke or heart failure. Rhythm control strategies are associated with increased hospitalization Rhythm control strategy should still be considered for: younger or symptomatic individuals, those with reversible etiologies
Thank you! michael.curley@ascension.org