What is the best strategy for managing atrial fibrillation in patients with heart failure?

Rhythm control is no better than rate control for patients with atrial fibrillation, even if they have left ventricular dysfunction. (LOE = 1b)

Roy D, Talajic M, Nattel S, et al, for the Atrial Fibrillation and Congestive Heart Failure Investigators. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med 2008; 358: 2667-2677.  [PMID:18565859]

Randomized controlled trial (double-blinded)

Unconcealed

Outpatient (any)

Previous studies have consistently shown no benefit to rhythm control over rate control in patients with atrial fibrillation (AF), provided they were anticoagulated. This study looked at the important subset of patients with AF who also have left ventricular dysfunction. In this study, researchers recruited 1376 patients with a left ventricular ejection fraction of less than 35% and an episode of AF lasting at least 6 hours or requiring cardioversion within the past 6 months or an episode lasting at least 10 minutes within the past 6 months and a history of cardioversion. Patients with persistent AF for more than 12 months were excluded. Their mean age was 66 years and 82% were men. Groups were fairly well balanced at the start of the study -- although there were more men in the rate control group -- and analysis was by intention to treat. The study was not masked and allocation did not appear to have been concealed. Follow-up was good, with 94% of patients completing follow-up or dying, and a median follow-up of survivors of 47 months. Most patients in the rhythm control group were taking amiodarone, and 90% of patients received an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and 90% were anticoagulated. Crossovers occurred in both directions: 21% from rhythm to rate (for inability to maintain sinus rhytm) and 10% from rate to rhythm (for worsening heart failure). There was no difference in the rates of cardiovascular death (27% for rhythm vs 25% for rate control) or all-cause mortality (32% vs 33%).