Patient-Oriented Evidence That Matters
In High-Risk Older Patients with Atrial Fibrillation, Rhythm Control Reduces Cardiovascular Death and Stroke, But at a Price
Am Fam Physician. 2021 Apr 1;103(7):440-441.
For older patients at high cardiovascular risk, is a strategy of rate control or rhythm control preferred for recent-onset atrial fibrillation (AF)?
In high-risk older patients with recent-onset AF, a strategy of rhythm control results in fewer cardiovascular deaths (number needed to treat [NNT] = 333 per year) and fewer strokes (NNT = 333 per year). However, there are more adverse events and complications and a small decrease in health-related quality of life. This is a decision that should be individualized, and these findings should not be extrapolated to younger and lower-risk populations without further evidence. (Level of Evidence = 1b)
Previous studies that compared rate control and rhythm control had mixed results. In this study, 2,789 older adults with an onset of AF within the past year were recruited. Participants had to be older than 75 years, have had a recent transient ischemic attack (TIA) or stroke, or have at least two of the following: older than 65 years, female sex, heart failure or left ventricular hypertrophy, hypertension, diabetes mellitus, chronic kidney disease, or severe coronary disease. At baseline, the mean age of participants was 70 years, 46% were women, 12% had a previous TIA or stroke, 12% had chronic kidney disease, 28% had heart failure, 88% had hypertension, and 44% had valvular heart disease. The groups were balanced at baseline, and analysis was by modified intention to treat of all patients who had at least one follow-up assessment. This was a very high-risk group of patients. The patients were randomized to receive rhythm control using medications or ablation, or rate control to manage symptoms. In the rhythm control group, recurrent AF triggered additional attempts to cardiovert the patient. In the rhythm control group after two years, 19.4% had undergone ablation, 21% were taking flecainide, 17.7% were taking amiodarone or dronedarone (Multaq), and 35% were taking no antiarrhythmic drug. In
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