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Original Investigation
July 9, 2012

Comparative Effectiveness of Rhythm Control vs Rate Control Drug Treatment Effect on Mortality in Patients With Atrial Fibrillation

Author Affiliations

Author Affiliations: Harvard School of Public Health, Harvard University, Boston, Massachusetts (Dr Ionescu-Ittu); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quebec, Canada (Drs Ionescu-Ittu, Abrahamowicz, Eisenberg, and Pilote and Mr Wynant); Divisions of Clinical Epidemiology (Drs Abrahamowicz and Pilote and Mr Richard), Cardiology (Dr Essebag), and General Internal Medicine (Dr Pilote), McGill University Health Center, Montréal; Western University of Health Sciences, Pomona, California (Dr Jackevicius); Institute for Clinical Evaluative Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Dr Jackevicius); and Division of Cardiology, Jewish General Hospital, Montréal (Dr Eisenberg).

Arch Intern Med. 2012;172(13):997-1004. doi:10.1001/archinternmed.2012.2266

Background Controversy continues concerning the choice of rhythm control vs rate control treatment strategies for atrial fibrillation (AF). A recent clinical trial showed no difference in 5-year mortality between the 2 treatments. We aimed to determine whether the 2 strategies have similar effectiveness when applied to a general population of patients with AF with longer follow-up.

Methods We used population-based administrative databases from Quebec, Canada, from 1999 to 2007 to select patients 66 years or older hospitalized with an AF diagnosis who did not have AF-related drug prescriptions in the year before the admission but received a prescription within 7 days of discharge. Patients were followed until death or administrative censoring. Mortality was analyzed by multivariable Cox regression.

Results Among 26 130 patients followed for a mean (SD) period of 3.1 years (2.3 years), there were 13 237 deaths (49.5%). After adjusting for covariates, we found that the effect of rhythm vs rate control drugs changed over time: after a small increase in mortality for patients treated with rhythm control in the 6 months following treatment initiation (hazard ratio [HR], 1.07; 95% CI, 1.01-1.14), the mortality was similar between the 2 groups until year 4 but decreased steadily in the rhythm control group after year 5 (HR, 0.89; 95% CI, 0.81-0.96; and HR, 0.77; 95% CI, 0.62-0.95, after 5 and 8 years, respectively).

Conclusions In this population-based sample of patients with AF, we found little difference in mortality within 4 years of treatment initiation between patients with AF initiating rhythm control therapy vs those initiating rate control therapy. However, rhythm control therapy seems to be superior in the long-term.