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Atrial fibrillation management strategies and early mortality after myocardial infarction: results from the Valsartan in Acute Myocardial Infarction (VALIANT) Trial
  1. Kent R Nilsson Jr1,
  2. Sana M Al-Khatib1,2,
  3. Yi Zhou2,
  4. Karen Pieper2,
  5. Harvey D White3,
  6. Aldo P Maggioni4,
  7. Lars Kober5,
  8. Christopher B Granger1,2,
  9. Eldrin F Lewis6,
  10. John J V McMurray7,
  11. Robert M Califf1,2,
  12. Eric J Velazquez1,2
  1. 1Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
  2. 2Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
  3. 3Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
  4. 4Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy
  5. 5Rigshospitalet, Copenhagen, Denmark
  6. 6Brigham and Women's Hospital, Boston, Massachusetts, USA
  7. 7Western Infirmary, Glasgow, Scotland, UK
  1. Correspondence to Dr Kent R Nilsson, Jr, Division of Cardiology, Department of Medicine, Duke University Medical Center, Erwin Road, DUMC 31009, Durham, NC 27710, USA; kent.nilsson{at}


Objective The management of patients with atrial fibrillation (AF) following a myocardial infarction (MI) remains uncertain. This study compared a rate control strategy to an anti-arrhythmic-based rhythm control strategy for the treatment of AF following myocardial infarction.

Design, setting and patients We studied 1131 patients with AF after MI who were enrolled in the Valsartan in Acute Myocardial Infarction Trial (VALIANT). We classified patients into those treated with a rhythm control strategy (n=371) and those treated with a rate control strategy (n=760).

Main outcomes measures Using Cox models, we compared the two groups with respect to both death and stroke during two different time periods after randomisation for which data collection had been pre-specified: 0–45 days and 45–1096 days.

Results After adjustment, a rhythm control strategy was found to be associated with increased early mortality (0–45 days: HR: 1.9, 95% CI 1.2 to 3.0, p=0.004) but not late mortality (45–1096 days: HR 1.1, 95% CI 0.9 to 1.4, p=0.45). No difference was observed in the incidence of stroke (0–45 days: HR 1.2, 95% CI 0.4 to 3.7, p=0.73; 45–1096 days: HR 0.6, 95% CI 0.3 to 1.3, p=0.21).

Conclusions In patients with AF after an MI, an anti-arrhythmic drug-based rhythm control strategy is associated with excess 45-day mortality compared with a rate control strategy, but is not associated with increased mortality outside of the immediate peri-infarct period. These results potentially identify a patient population in whom the use of anti-arrhythmic drug therapy may portend an increased risk of death.

  • Atrial fibrillation
  • myocardial infarction
  • rate control
  • rhythm control
  • atrial arrhythmias
  • acute coronary syndrome

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  • Funding This analysis was supported, in part, by a grant from Glaxo-Smith Kline. The VALIANT trial was supported by a grant from Novartis Pharmaceuticals.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Duke University Medical Center Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.