Rhythm control is a cornerstone of therapy for nonvalvular atrial fibrillation (AFib) and it can significantly improve AFib symptoms. However, this treatment may be underused in outpatient centers across the U.S., and there is substantial practice variation, according to a randomized clinical trial recently published in the American Heart Journal.

Anil K. Gehi, MD, et al., used data from ACC’s PINNACLE Registry to analyze treatment decisions for 511,958 patients who were diagnosed with nonvalvular AFib between May 1, 2008 and Dec. 31, 2014. Most patients were elderly (72 years) and white (62 percent) and had a variety of comorbidities and moderate-high CHADS₂ (1.9 ± 1.3) and CHA₂DS₂-VASc (3.6 ± 1.8) scores.

Results showed that only one in five AFib patients received rhythm control, while only one in 50 received catheter ablation, the most recent innovation in AFib treatment. The study assessed patient (age, gender, race, insurance type and more) and practice (number of providers, area type and practice region) factors associated with rhythm control treatment.

Patients who received rhythm control were more likely to be younger (69 years), white (76 percent) and privately insured (56 percent) than those who were not treated with rhythm control therapy (72 years old, 58 percent white and 51 percent privately insured).

Additionally, there was significant variation in the proportion of patients who received rhythm control based on practice factors (median 22.8 percent; range 0.2- 62.9 percent). The proportion of AFib patients who received catheter ablation also varied (median 0.3 percent; range zero to 100 percent). Nearly half (46.1 percent) of practices using rhythm control did not treat patients with catheter ablation.

“Our finding that race, insurance and whether a patient was seen by an EP [electrophysiologist] physician are significant patient and practice factors associated with rhythm control further suggests that differential access, potentially by socioeconomic status, may be a driver of differential treatments,” write the study authors.

They conclude that “although current guidelines suggest that patient factors […] should guide treatment decisions, there is evidence of large unexplained practice variation and unnecessary patient factor variation in rhythm control and catheter ablation decisions. By identifying the factors that lead to differences in treatment strategies, we can determine their appropriateness and better align rhythm control use to optimize patient outcomes in AF[ib].”

Keywords: United States, Atrial Fibrillation, Catheter Ablation, Comorbidity, Outpatients, Registries, Electrophysiological Phenomena, Social Class

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