Outcomes in Atrial Fibrillation Patients With and Without Ventricular Hypertrophy When Treated With a Lenient Rate-Control or Rhythm-Control Strategy

Study Questions:

Does left ventricular hypertrophy (LVH) affect outcomes in patients with atrial fibrillation (AF) managed with a rate-control or rhythm-control strategy?


In this post-hoc analysis of the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial, LV mass was calculated from echocardiographic measurements in 2,105 patients (mean age 69.4 years). LVH was moderate or severe in 299 and 725 patients, respectively. Strict rate control was defined as a resting heart rate ≤80 bpm and a rate ≤110 bpm after a 6-minute walk. The primary endpoint was all-cause mortality.


All-cause mortality was 15.7% at a median of 41.5 months of follow-up. Severe LVH was independently predictive of mortality in the rhythm-control arm (hazard ratio [HR], 1.6), but not in the rate-control arm. Among the 366 patients in the rate-control arm, 261 patients (71%) had lenient rate control and 105 (29%) had strict control. Moderate to severe LVH was not a predictor of mortality in either the lenient or strict rate-control group. Moderate to severe LVH was a significant predictor of cardiovascular hospitalization in the lenient rate-control group (HR, 1.72), but not the strict rate-control group.


The authors concluded that moderate/severe LVH is an independent predictor of mortality in patients with AF managed with a rhythm-control strategy and a predictor of worse outcomes when a lenient rate-control strategy is used.


The higher risk of proarrhythmia in patients with LVH probably explains why LVH is associated with higher mortality in patients treated with a pharmacologic rhythm-control strategy. A rapid rate is deleterious in patients with impaired diastolic filling, probably explaining why strict rate control is better than lenient control in patients with LVH.

Clinical Topics: Noninvasive Imaging, Echocardiography/Ultrasound

Keywords: Hypertrophy, Left Ventricular, Echocardiography

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