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Rate versus Rhythm Control in Patients with Normal to Mild Left Atrial Enlarge-ment: Insights from the AFFIRM Trial


Background: Atrial fibrillation is the most commonly encountered sustained arrhythmia and is associated with significant morbidity and mortality. Several trials have demonstrated that no mortality benefit exists when choosing a rhythm-control strategy over a rate-control strategy, with some trials suggesting an increase in mortality. Using the AFFIRM trial database we sought to determine the effect of rhythm control strategy in patients with normal or mild atrial enlargement. Methods: AFFIRM Trial database was used to evaluate the effect of rhythm-control strategy com-pared to rate-control strategy in a subgroup of patients with normal to mild left atrial (LA) enlargement. The primary outcome measures of this study were all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, and hospitalization/ED visit. Results: We identified a subgroup of subjects from the AFFIRM trial with normal or mild LA en-largement (n=2022 of 4060 total subjects). Subjects in the rhythm-control group (n= 1022) had an increased risk of all-cause mortality by 34% (RR 1.34, 95% CI 1.08-1.67; P=0.007) and hospitalization/ED visits by 10% (RR 1.10, 95% CI 1.05-2.16; P=<0.001) compared to rate control group (n= 1000). Subjects in the rhythm-control group (n= 334) who was on amiodarone as initial anti-arrhythmic medications had an increased risk of all-cause mortality by 39% (RR 1.39, 95% CI 1.04-1.85; P=0.027) compared to rate control group (n= 1000). In contrast, subjects in the rhythm-control group (n= 322) who was on sotalol as initial anti-arrhythmic medication did not have an increased risk of all-cause mortality compared to rate control group (n= 1000). Conclusion: This study demonstrated that rhythm-control strategy increases the risk of mortality and hospitalization in a subgroup of patients with normal to mild atrial enlargement com-pared to rate-control strategy. Amiodarone use in this subgroup of patients likely drove these findings.

Credits: Talal Alzahrani, MD, MPH1, James McCaffrey, MD1, Marco Mercader, MD, FACC, FHRS1, Allen Solomon, MD, FACC, FHRS1



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