Management of atrial fibrillation with the rhythm-control strategy offers no survival advantage over the rate-control strategy, and there are potential advantages, such as a lower risk of adverse drug effects, with the rate-control strategy. Anticoagulation should be continued in this group of high-risk patients.
The AFFIRM Investigators* Background-The AFFIRM Study showed that treatment of patients with atrial fibrillation and a high risk for stroke or death with a rhythm-control strategy offered no survival advantage over a rate-control strategy in an intention-to-treat analysis. This article reports an "on-treatment" analysis of the relationship of survival to cardiac rhythm and treatment as they changed over time. Methods and Results-Modeling techniques were used to determine the relationships among survival, baseline clinical variables, and time-dependent variables. The following baseline variables were significantly associated with an increased risk of death: increasing age, coronary artery disease, congestive heart failure, diabetes, stroke or transient ischemic attack, smoking, left ventricular dysfunction, and mitral regurgitation. Among the time-dependent variables, the presence of sinus rhythm (SR) was associated with a lower risk of death, as was warfarin use. Antiarrhythmic drugs (AADs) were associated with increased mortality only after adjustment for the presence of SR. Consistent with the original intention-to-treat analysis, AADs were no longer associated with mortality when SR was removed from the model.
Conclusions-Warfarin
Modest improvement in 6-min walk distance was noted in the rhythm-control arm. Presence of AF was associated with worse NYHA-FC. No difference in cognitive function was detected.
Background--Blockers are known to reduce total mortality and sudden death in survivors of recent myocardial infarction. The effects of these agents in patients at high risk for sudden death with remote infarction are not clear. Methods and Results-We analyzed the effect of -blockers on outcomes in 2096 patients with coronary artery disease, ejection fraction Յ40%, and spontaneous nonsustained ventricular tachycardia enrolled in the Multicenter UnSustained Tachycardia Trial (MUSTT). Forty-five percent of 702 patients with inducible sustained ventricular tachyarrhythmia and 35% of 1394 patients without inducible tachycardia were discharged from hospital receiving -blockers. Patients treated with -blockers were younger and had higher ejection fractions, higher rates of recent angina, and more recent infarction. -Blockers were associated with decreased total mortality for the entire study population (5-year mortality 50% with -blockers versus 66% without -blockers; adjusted Pϭ0.0001). The mortality benefit associated with -blockers was present in patients with and without inducible tachycardia, except those treated with implantable defibrillators. There was no significant effect of -blocker therapy on the rate of arrhythmic death or cardiac arrest (adjusted Pϭ0.2344). Conclusions--Blocking agents have beneficial effects on survival of patients having characteristics of those enrolled in the MUSTT trial. These effects do not appear to be due to a specific antiarrhythmic effect of -blockers. The beneficial effects of -blockers were demonstrable in all patients except those treated with implantable defibrillators. (Circulation.
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