Dr. Denis Roy
Presenter: Roy, Denis (Canada)
Discussant Report:Maggioni, Aldo PietrowebcastThe AF-CHF trial is a multicenter, prospective, randomized, open label trial that randomized 1376 patients with HF and LVEF <35% with a history of AF to rhythm control vs rate control. Over a follow-up period of 37 months rhythm control did not improve patient outcomes as compared to a rate control strategy.
Was this trial necessary? The (re)occurrence of AF in patients with HF and LVD is associated with a worse prognosis. Several RCTs have shown that rhythm control in patients with AF does not improve prognosis with respect to rate control. However, a small number of patients with HF/LVD have been included in these RCTs. Therefore, whether the prevention of AF in patients with both HF and LVD is associated with an improvement of survival was still an open question.
Were study drugs effective? Sinus rhythm could be documented at repeated assessments in 75-80% of patients in the rhythm-control group, while in the rate-control group, heart rate targets were achieved in more than 80% of patients during follow-up. However, 58% of the patients of the rhythm control group had at least one recurrence of AF during follow-up, demonstrating that antiarrhythmic drug therapy is surely suboptimal.
Why was rhythm control not superior to rate control strategy? AF could be a marker of poor prognosis but without an independent effect on outcome. The effects of strategies could be diluted by (a) suboptimal maintenance of SR by rhythm control strategies and (b) the fact that just 60% of patients in rate control strategy actually have persistent AF. Furthermore, the beneficial effects of rhythm maintenance could have been counterbalanced by the toxicity of antiarrhythmic drugs and by the significantly higher rate of use of beta blockers in rate control strategy, which could have favorably influenced patient survival.
In conclusion, while waiting for further evidence on new drugs and ablation techniques (not only in terms of efficacy in SR maintenance, but also in terms of survival improvement), the results of AF-CHF reinforce the concept that rate control strategy should be considered the first choice for patients with HF/LVD and AF and that antiarrhythmic drugs for rhythm control should be considered only in selected cases if symptoms persist.
Clinical Trial Update II
This congress report accompanies a presentation given at the ESC Congress 2008. Written by the author himself/herself, this report does not necessarily reflect the opinion of the European Society of Cardiology
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