Comparison of Rate and Rhythm Control in Hypertension Patients With Atrial Fibrillation

Abstract

trial fibrillation (AF) is the most frequent reason for hospital admission and is also the most common sustained cardiac arrhythmia, occurring in 0.4% of the adult population. 1,2 Its prevalence is age-related and increases significantly to 1-4% after 60 years of age. [1][2][3] Owing to the age structure of Turkey's population and the increasing morbidity and comorbidity, one must assume that this arrhythmia will reach an even higher prevalence. AF is associated with a significantly higher risk of systemic embolism, congestive heart failure and death. [1][2][3][4] AF and hypertension are 2 prevalent, and often coexisting, conditions in the adult population. 5-7 Their incidence increases with age, and they are responsible for considerable morbidity and mortality. 5,6 The purpose of the present study was to determine whether a strategy that attempts to restore and maintain sinus rhythm (SR) in AF will improve survival and exercise capacity among patients with hypertension. MethodsPatients aged >18 years who had hypertension and persistent AF for >48 h were included in the study. AF was defined as having: an absence of P-waves, course or fine fibrillatory waves, and completely irregular R-R intervals.The diagnosis of essential hypertension was defined as having BP >140/90 mmHg, or current use of antihyperten- Patients suffering from valvular heart diseases, coronary artery disease, heart failure, thyroid disease, renal failure, sick sinus syndrome, pulmonary embolism, acute pericarditis, diabetes mellitus, chronic obstructive lung disease, hypertrophic obstructive cardiomyopathy and atrial thrombus were excluded from the study.The patients were randomly assigned to either the rhythm control group or rate control group. The patients were kept under observation for a minumum follow-up period of 3 years, with regular weekly visits in the 1 st month and then once a month thereafter. The composite endpoints of the study were embolism, death and exercise capacity for both groups.At baseline, resting 12-lead ECG was obtained, and transthoracic echocardiography (TTE), transesophageal echocardiograph (TEE) and exercise tests were performed. At every control visit, a 12-lead ECG was taken. At the end of the 1 st year all patients underwent exercise testing.The TTE and TEE studies were performed with an Acuson 128 XP/5 ultrasound system. M-mode TTE was used to measure the left atrial dimension at end-systole and the LVEF, according to the recommendations of the American Society of Echocardiography. Food consumption was stopped at least 4 h before the TEE was done. Patients received local pharyngeal anesthesia (1% lidocaine spray) as the only premedication, and were given effective anticoagulation either with heparin or warfarin (INR levels 2.0-3.0 or APTT 2 times control, 60-80 s) before the TEE. Patients in whom the TEE did not detect any thrombus were cardioverted to SR. For cardioversion (CV), amiodarone (administered intravenously (iv)) was used (300 mg over 1 h, then 15-20 mg/kg for the remaining 23 h). If CV was not ach...

Systematic Review and Meta-analysis of the Efficacy of Cardioversion by Vernakalant and Comparators in Patients with Atrial Fibrillation

“…Rhythm control is recommended for younger patients with recent-onset or paroxysmal AF and those with shorter duration AF (≤ 48 h) [6,9]. Although existing evidence does not show one approach to be clearly superior to the other [10][11][12][13][14][15], in AF patients with distressing symptoms and/or seriously compromised cardiac function, it is of particular interest that cardioversion be achieved rapidly [5][6][7][8]16], as delayed cardioversion may worsen AF-associated symptoms and promote structural remodeling of the atria [17]. While various cardioversion therapies exist, their limitations, including limited use in certain comorbid patients, drug-drug interactions, and slow cardioversion rates, highlight the need for new treatments that are safer, more effective, and more timely in action [6,[18][19][20][21][22][23][24][25][26][27][28].…”

Comparative effectiveness of antiarrhythmic drugs on cardiovascular hospitalization and mortality in atrial fibrillation

“…Nineteen (50%) out of the 38 identified articles evaluated individual AADs [13,[16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] and 13 studies (34%) compared multidrug strategies of rate versus rhythm control [34][35][36][37][38][39][40][41][42][43][44][45][46]. The remaining six articles (16%) evaluated multiple agents but did not report outcomes for individual agents [47][48][49][50][51][52].…”

“…Out of the 29 articles reporting end points related to CV mortality, 15 examined the effects of individual AADs (amiodarone, azimilide, dofetilide, dronedarone, propafenone, quinidine and sotalol; table 2) [13,[17][18][19][20][22][23][24][25][26][27][28][29][30][31]. Eight studies evaluated a single AAD (azimilide, dofetilide, dronedarone and quinidine) versus placebo [13,17,19,[22][23][24]29].…”

“…When end points related to CV mortality were subcategorized according to specific outcomes, most (13) publications reported arrhythmia-associated mortality (table 3) [13,[17][18][19][20][22][23][24][25][26][27]30,31]. Out of these 13 articles, six reported studies were judged to be good quality by the AHRQ CER criteria [13,17,[22][23][24]27].…”

“…Amiodarone 1 [27] 3 [18, 28,31] 2 [25,30] -3 [25,27,31] 3 [18, 28,30] Azimilide 1 [22] Other studies that reported a statistically significant reduction in an end point related to CV mortality or CV hospitalization were rated as fair [21] or poor quality (table 4) [17,23,30].…”