Results from the first trial to examine rhythm vs. rate control in heart failure patients with atrial fibrillation, the Atrial Fibrillation and Congestive Heart Failure Trial (AF-CHF), have been reported in the New England Journal of Medicine. The study, also presented at Cardiostim 2008, was a prospective, multi-centre project involving patients with heart failure and atrial fibrillation.
The trial was launched in 2001 and enrolled 1,376 patients at 123 hospital sites in North America, South America, Europe and Israel. The project’s goal was to improve treatment with the objective of reducing mortality and morbidity linked with atrial fibrillation and heart failure. Made possible by a grant of more than US$6.5 million from the Canadian Institutes of Health Research (CIHR), this study was directed by Dr Denis Roy, a cardiologist at the Montreal Heart Institute (MHI) and Chair of the Department of Medicine at the Université de Montréal, Canada, in collaboration with Dr Mario Talajic, also a cardiologist at the MHI, and several Canadian researchers and international experts who contributed to this large-scale research project.
Between May 2001 and June 2005, the 1,376 patients were randomly assigned to a rhythm-control strategy or a more simpler strategy of rate-control. The primary endpoint of the study was cardiovascular mortality.
The intention-to-treat analysis revealed no difference in the primary endpoint between the two groups. Cardiovascular death occurred in 182 (27%) patients in the rhythm-control group compared with 175 (25%) in the rate-control arm. Total mortality, worsening heart failure and stroke were similar between the two groups. Hospitalisations were more frequent in the rhythm-control group, many due to hospitalisation for management of atrial fibrillation.
Rate-control should be the primary approach
According to the researchers, the AF-CHF trial provides important new information concerning two widely-used treatment strategies for atrial fibrillation in patients with heart failure. The routine use of a rhythm-control strategy did not reduce the rate of death in comparison with a rate-control strategy. Furthermore, there were no significant differences in other important outcomes such as worsening heart failure or stroke. The rate-control strategy eliminated the need for repeated cardioversions and reduced rates of hospitalisation. In conclusion, the results of this trial suggest that rate-control, should be considered the primary approach for patients with atrial fibrillation and congestive heart failure.
“It is now clear that the rate-control strategy offers a less complex approach for the management of atrial fibrillation and could reduce rates of hospitalisation,” said Roy. “The result of this provocative study challenges the conventional wisdom, and shows that these patients can be conservatively managed, without repeated electric shocks. This will serve as a new goal post for future care of these patients,”said Dr Peter Liu, Scientific Director of the CIHR Institute of Circulatory and Respiratory Health.