Rhythm Control for Atrial Fibrillation With Heart Failure

Study Questions:

What are the benefits of a rhythm control strategy in patients with atrial fibrillation (AF) and heart failure (HF)?


This was a pooled analysis of randomized studies comparing either rhythm control using antiarrhythmic drugs (AADs) versus rate control (Subset A, four studies, 2,486 patients) or catheter ablation (CA) versus rate control (Subset B, seven studies, 1,112 patients) in patients with AF and HF. The primary outcomes were all-cause mortality, re-hospitalization, stroke, and thromboembolic events.


In Subset A, the AAD group had a similar incidence of death, stroke, and thromboembolic events as the rate control group, but a higher incidence of re-hospitalization (odds ratio [OR], 1.25). In Subset B, the CA group had a lower incidence of death (OR, 0.51), re-hospitalization (OR, 0.44), and recurrent AF (30% vs. 80%); greater improvement in ejection fraction (mean 6.8%) and quality of life; and a similar incidence of stroke events compared to the rate control group.


Compared to rate control, CA (but not a rhythm-control strategy using AADs) results in a major improvement in outcomes in patients with AF and HF.


The results emphasize the importance of restoring sinus rhythm in patients with AF and HF. At first glance, the results of this study appear to be at odds with the results of the CABANA trial, in which CA did not reduce the composite endpoint of mortality, stroke, bleeding, or cardiac arrest compared to AAD therapy, even in patients with HF. However, this was based on an intention-to treat analysis and >25% of patients in the AAD group crossed over to CA. A subsequent on-treatment analysis demonstrated that CA did indeed improve outcomes.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Heart Failure, Quality of Life, Secondary Prevention, Stroke, Stroke Volume, Thromboembolism

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