Elsevier

American Heart Journal

Volume 149, Issue 6, June 2005, Pages 1106-1111
American Heart Journal

Clinical Investigation
Electrophysiology
Rate control versus rhythm control for patients with persistent atrial fibrillation with mild to moderate heart failure: Results from the RAte Control versus Electrical cardioversion (RACE) study

https://doi.org/10.1016/j.ahj.2004.11.030Get rights and content

Background

This study was conducted to compare rate- and rhythm-control therapy in patients with persistent atrial fibrillation (AF) and mild to moderate chronic heart failure (CHF).

Rate control is not inferior to rhythm control in preventing mortality and morbidity in patients with AF. In CHF, this issue is still unsettled.

Methods

In this predefined analysis of the RACE study, a total of 261 patients were in New York Heart Association (NYHA) classes II and III at baseline. These patients were analyzed. The primary end point was a composite of cardiovascular mortality, hospitalization for CHF, thromboembolic complications, bleeding, pacemaker implantation, and life-threatening drug side effects. Furthermore, quality of life was compared.

Results

After 2.3 ± 0.6 years, the primary end point occurred in 29 (22.3%) of the 130 rate-control patients and in 32 (24.4%) of the 131 rhythm-control patients. More cardiovascular deaths, hospitalization for CHF, and bleeding occurred under rate control. Thromboembolic complications, drug side effects, and pacemaker implantation were more frequent under rhythm control. Quality of life did not differ between strategies. In patients successfully treated with rhythm control, the prevalence of end points was not different from those who were in AF at study end. However, the type of end point was different: mortality, bleeding, hospitalization for heart failure, and pacemaker implantation occurred less frequently.

Conclusions

In patients with mild to moderate CHF, rate control is not inferior to rhythm control. However, if sinus rhythm can be maintained, outcome may be improved. A prospective randomized trial is necessary to confirm these results.

Section snippets

Study design

In the RACE study, 522 patients with persistent AF were included from June 1, 1998, until July 1, 2001. In the present study, only patients with CHF in NYHA functional classes II and III at inclusion were selected from the original population. A total of 261 patients were analyzed with 130 and 131 patients randomized to rate- and rhythm-control groups, respectively.

A detailed description of the RACE design was recently published.3, 16 In short, rate control was achieved using negative

Patient characteristics

A total of 261 patients with AF in NYHA functional classes II and III for CHF were included in this study (Table I). Except for slightly more patients with hypertension in the rhythm-control strategy, no other significant differences in clinical characteristics between the groups were present.

Treatment

After a mean follow-up of 2.3 ± 0.6 years, 47 (36%) patients in the rhythm-control group were in sinus rhythm. Use of antiarrhythmic drugs and cardioversions were comparable to the main study. In the

Discussion

The present study shows that in patients with AF and mild CHF the occurrence of cardiovascular morbidity and mortality is comparable between those treated with rate control and those treated with rhythm control. However, we observed an important difference in the type of end points between both groups. There was a trend for a higher mortality and major bleedings under rate control. In addition, rhythm control was associated with excellent survival if sinus rhythm could be maintained. Of note,

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