Routine vs. Aggressive upstream rhythm Control for prevention of Early persistent atrial fibrillation in heart failure study - RACE 3

Contribution To Literature:

The RACE 3 trial showed that upstream risk factor modification was superior at maintaining sinus rhythm.

Description:

The goal of the trial was to evaluate upstream risk factor modification compared with conventional therapy among patients with early persistent atrial fibrillation.

Study Design

  • Randomized
  • Parallel

Patients with early persistent atrial fibrillation and heart failure were randomized to upstream therapy (n = 119) versus conventional therapy (n = 126).

Upstream therapy consisted of mineralocorticoid receptor antagonist, statin, angiotensin-converting enzyme (ACE) inhibitor and/or angiotensin receptor blocker, and cardiac rehabilitation.

Inclusion criteria:

  • Early persistent atrial fibrillation and mild to moderate heart failure
  • Total atrial fibrillation history <5 years, total persistent duration >7 days but <6 months, and ≤1 electrical cardioversion
  • History of heart failure <1 year with preserved ejection fraction or left ventricular ejection fraction ≥45%
  • Total number of enrollees: 245
  • Duration of follow-up: 1 year

Principal Findings:

The primary outcome, incidence of sinus rhythm at 1 year, occurred in 75% of the upstream therapy group versus 63% of the conventional therapy group (p = 0.021).

Interpretation:

Among patients with early persistent atrial fibrillation, upstream risk factor modification was effective at maintaining sinus rhythm at 1 year. Use of mineralocorticoid receptor antagonists, statins, ACE inhibitor and/or angiotensin receptor blockers, and cardiac rehabilitation can be considered in patients with persistent atrial fibrillation.

References:

Rienstra M, Hobbelt AH, Alings M, et al. Targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent atrial fibrillation: results of the RACE 3 trial. Eur Heart J 2018;Feb 1:[Epub ahead of print].

Editorial: Pavlovic D, Kirchhof P, Fabritz L, et al. The RACE-3 is on: double-locking sinus rhythm by upstream and downstream therapy. Eur Heart J 2018;Feb 7:[Epub ahead of print].

Presented by Dr. Michiel Rienstra at the European Society of Cardiology Congress, Barcelona, Spain, August 27, 2017.

Clinical Topics: Arrhythmias and Clinical EP, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Nonstatins, Novel Agents, Statins, Acute Heart Failure

Keywords: Angiotensin-Converting Enzyme Inhibitors, Angiotensin Receptor Antagonists, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Rehabilitation, ESC Congress, ESC2017, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Mineralocorticoid Receptor Antagonists, Primary Prevention, Risk Factors


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