Perspective:

In a recent EAST-AFNET 4 trial, in patients with AF and concomitant cardiovascular conditions, a rhythm control strategy instituted within 1 year of diagnosis was associated with better cardiovascular outcomes than a rate control strategy. In a subgroup analysis, the effect was consistent across different age subgroups (<68, 68-74, >74 years of age). The authors of the present study analyzed the national Korean health database to assess whether they would observe similar effects. They found that protective association of rhythm control over rate control was attenuated with advancing age. Early rhythm control in patients <75 years of age was associated with a 20% decreased risk of adverse cardiovascular outcomes when compared with rate control, but the older patients undergoing early rhythm control did not show benefit. The randomized study and the national database differed in how rhythm strategy was implemented, with the Korean patients having higher prevalence of comorbidities, significantly fewer ablation procedures, and significantly more amiodarone use. Still there was a trend toward lower risk of ischemic stroke and AMI with the use of rhythm control strategy in the elderly. Future prospective randomized studies should examine the potential benefit or a lack thereof in patients >75 years of age treated with a rhythm control strategy.