Age and Effect of Early Rhythm Control for Atrial Fibrillation

Quick Takes

  • A population-based study of 31,220 patients with AF from the Korean National Health Insurance Service database showed that an early rhythm control (drug or ablation) strategy was associated with better cardiovascular outcomes than a rate control strategy in patients aged <75 years.
  • The protective association was attenuated with advancing age, and patients who were ≥75 years of age no longer had statistically significant reductions in the composite of adverse cardiovascular outcomes, although there was a trend toward lower risks of ischemic stroke and AMI.

Study Questions:

Do the effects of early rhythm control in atrial fibrillation (AF) differ according to age?


This was a retrospective population-based cohort study of 31,220 patients with AF from the Korean National Health Insurance Service database. Outcomes were analyzed according to whether a patient underwent rhythm control (antiarrhythmic drugs or ablation) or rate control. A composite outcome of cardiovascular death, ischemic stroke, hospitalization for heart failure, or acute myocardial infarction (AMI) was compared in subgroups stratified by age.


Compared with rate control, early rhythm control was associated with a lower risk of the primary composite outcome in patients <75 years of age (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.72-0.88). The protective association between early rhythm control and cardiovascular outcomes exhibited a linear decrease with advancing age, with declined benefits in patients ≥75 years of age (HR, 0.94; 95% CI, 0.87-1.03; p for interaction = 0.045). There was lower risk of ischemic stroke (HR, 0.78; 95% CI, 0.67-0.90) and AMI (HR, 0.63; 95% CI, 0.41-0.97) in the older adults who were managed with rhythm control strategy. No significant differences in safety outcomes were found across different ages.


The beneficial association of early rhythm control with cardiovascular outcomes was attenuated with increasing age, with the larger benefits in younger patients <75 years of age. No differences were found by age in treatment-related safety outcomes.


In a recent EAST-AFNET 4 trial, in patients with AF and concomitant cardiovascular conditions, a rhythm control strategy instituted within 1 year of diagnosis was associated with better cardiovascular outcomes than a rate control strategy. In a subgroup analysis, the effect was consistent across different age subgroups (<68, 68-74, >74 years of age). The authors of the present study analyzed the national Korean health database to assess whether they would observe similar effects. They found that protective association of rhythm control over rate control was attenuated with advancing age. Early rhythm control in patients <75 years of age was associated with a 20% decreased risk of adverse cardiovascular outcomes when compared with rate control, but the older patients undergoing early rhythm control did not show benefit. The randomized study and the national database differed in how rhythm strategy was implemented, with the Korean patients having higher prevalence of comorbidities, significantly fewer ablation procedures, and significantly more amiodarone use. Still there was a trend toward lower risk of ischemic stroke and AMI with the use of rhythm control strategy in the elderly. Future prospective randomized studies should examine the potential benefit or a lack thereof in patients >75 years of age treated with a rhythm control strategy.

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

Keywords: Acute Coronary Syndrome, Amiodarone, Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Brain Ischemia, Catheter Ablation, Geriatrics, Heart Failure, Heart Rate, Ischemic Stroke, Myocardial Infarction, Secondary Prevention, Stroke, Treatment Outcome, Vascular Diseases

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