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| |  Routine Rhythm-Control Not Better Than Rate-Control for Heart Failure: Presented at ESC By Chris Berrie MUNICH, Germany -- September 5, 2008 -- Routine use of a rhythm-control strategy does not improve outcomes compared with a rate-control strategy in patients with congestive heart failure, according to a study presented here at the European Society of Cardiology 2008 Congress (ESC). Principal investigator Denis Roy, MD, Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada, presented the multicentre, prospective, randomised, open-label study on September 2 on behalf of the Atrial Fibrillation and Congestive Heart Failure trial investigators. "The [study's] hypothesis was that restoring and maintaining sinus rhythm will reduce cardiovascular mortality when compared to a rate-control strategy in patients with atrial fibrillation and heart failure," Dr. Roy said. For their study, Dr. Roy and colleagues enrolled patients with heart failure, New York Heart Association (NYHA) class II to IV, left ventricular ejection fraction <=35%, and a history of atrial fibrillation. They randomised 682 patients a mean of 66 years old (male, 78%) to treatment by a rhythm-control strategy and 694 patients a mean of 67 years old to treatment by a rate-control strategy (male, 85%). There were no significant differences in patient baseline characteristics between the 2 treatment groups. Rhythm control included the use of antiarrhythmic drugs and/or nonpharmacological therapy in treatment-resistant patients, with cardioversion if needed. Rate control was based on pharmacological dosing adjustment to achieve a heart rate of <80 bpm at rest and <110 bpm during the 6-minute-walk test, with atrioventral-node ablation for patients with inadequate rate control. Over the mean follow-up of 37 months and the median follow-up of 47 months for surviving patients, all patients were on optimal congestive heart failure management. At 12 months, more of the rhythm-control patients were on amiodarone and sotalol. In comparison, more of the rate-control patients were on beta-blockers, digoxin, and oral anticoagulants. Use of all other medications was similar and optimal in the 2 groups. The prevalence of atrial fibrillation in the rhythm-control group was 54% at baseline, 17% at 4 months, and remained <20% for most of the study. For the rate-control group, prevalence of atrial fibrillation remained high (>=60%) throughout the study period. Dr. Roy also noted, "In the rate-control group, heart-rate targets were achieved in 82% to 88% of patients during the follow-up period." For the primary outcome of cardiovascular mortality, there was no significant difference between the treatment groups (hazard ratio [HR], 1.06). Similarly, no significant differences were seen for the prespecified secondary outcomes of cardiovascular death (HR, 0.97), stroke (HR, 0.74), worsening heart failure (HR, 0.87), and their composite (HR, 0.90). For patient functional status as either proportion of NYHA class III/IV or the 6-minute walk test and of patient quality of life, all showed no significant differences across the rhythm-control and rate-control groups throughout the study period. "These consistent results lend further support to the notion that maintenance of sinus rhythm does not yield additional benefits in patients with atrial fibrillation and heart failure," added Dr. Roy.
[Presentation title: Atrial Fibrillation and Congestive Heart Failure (AF-CHF) Trial. Abstract 3269]
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