Rhythm control with catheter ablation and rate control with drugs and/or a pacemaker performed similarly in patients with atrial fibrillation (AFib) and heart failure (HF) for the primary outcome of time to death or HF progression, according to results from the RAFT-AF trial presented May 17 during ACC.21. However, the trial was stopped early and had limiting statistical power to reveal differences between the two strategies.

In what the investigators say is the first of its kind, the trial included patients with AFib plus HF with reduced ejection fraction (HFrEF; n=240) and with preserved ejection fraction (HFpEF; n=171). In the trial, which was a prospective randomized open blinded endpoint trial, researchers enrolled 411 patients treated for HF at 21 medical centers in Canada, Sweden, Brazil and Taiwan. Participants were 67 years old on average and about 75% were men. About half were randomized to rhythm control and half to rate control; in the rate control arm if the desired heart rate was not achieved with medications, a pacemaker was implanted.  

During a median follow-up of 37 months, 23.4% of patients in the rhythm control arm and 32.5% of those in the rate control arm died or had progressive HF requiring acute HF treatment (hazard ratio [HR], 0.71; p=0.066). Among patients with HFrEF, the composite primary endpoint occurred in 22.8% of patients in the rhythm control arm and 37.1% of patients in the rate control arm (HR, 0.63 vs. HR, 0.88 in HFpEF).

According to the researchers, the findings suggest rhythm control may be beneficial for patients with HFrEF, though more research is needed to confirm this trend.  

The researchers also noted that patients in the rhythm control group had greater improvement in left ventricular function, quality of life and reduction in NT-proBNP compared with the rate control group. No difference was seen in terms of serious adverse events between the groups.

"The study didn't have a sufficient sample size to be definitive, but it is highly suggestive that ablation-based rhythm control appears to reduce the primary outcome measures, along with secondary outcomes of quality of life and [HF] markers, in patients who have [HFrEF]," said Anthony S.L. Tang, MD, the study's lead author. "It's not quite as conclusive as I'd like it to be, but I think it still is useful to help individual physicians determine treatment strategies. I would be less inclined to use the rhythm control strategy for [HFpEF] and more likely to use it in people with reduced ejection fraction."

Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: ACC Annual Scientific Session, ACC21, Geriatrics, Arrhythmias, Cardiac, Atrial Fibrillation, Heart Failure

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