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Pharmacological rhythm versus rate control in patients with atrial fibrillation and heart failure: the CASTLE-AF trial

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Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Background

The value of antiarrhythmics to maintain normal sinus rhythm in patients with atrial fibrillation (AF) and heart failure (HF) is still being debated. We aimed to determine whether rhythm control using antiarrhythmic drugs (AADs) is more effective than rate control in improving outcomes in this population.

Method

In this sub-analysis of the CASTLE-AF study, we included patients that were treated pharmacologically either to maintain sinus rhythm or to achieve rate control. The primary endpoint was defined as a composite of death from any cause or worsening of HF that led to an unplanned overnight hospitalization.

Result

Among 210 patients (mean age of 64.1 ± 10.8 years, 83.3% male) treated pharmacologically, 60 patients were in the rhythm control group and 150 were in the rate control group. Patients in the rhythm control group were less likely to be assigned a beta-blocker (53 (88.3%) vs 141 (97.9%), P = 0.004) and digitalis (8 (13.3%) vs 53 (36.8%), P < 0.001). Over a median follow-up of 3.76 (95% confidence interval (CI), 3.23, 4.48) years, the primary composite endpoint of all-cause mortality and HF admissions occurred in 23 patients (38.3%) in the rhythm control arm vs 67 (44.7%) in the rate control arm (hazard ratio, 0.99; 95% CI, 0.62 to 1.60; P = 0.976).

Conclusion

In CASTLE-AF among AF patients with HF, rhythm control with AADs did not significantly reduce the primary composite endpoint of all-cause mortality and HF hospitalization when compared with a pharmacological rate control strategy.

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Funding

This work was supported by Biotronik. Dr. Marrouche reports receiving grant support and consulting fees from Abbott, Medtronic, Biosense Webster, Boston Scientific, GE Health Care, and Siemens, receiving consulting fees from Preventice, and holding equity in Marrek and Cardiac Design. Dr. Sohns has received modest lecture honoraria and congress sponsoring from Abbott, Biosense Webster, and Medtronic. Dr. Brachmann has received consulting fees from Abbott, St. Jude Medical, Medtronic, Bayer, Livanova, Pfizer, Boston Scientific, Boehringer Ingelheim, and Biotronik. Dr. Boersma has received consulting fees, paid to his institution, from Medtronic and Boston Scientific. Dr. Sanders has received grant support, from serving on an advisory board, and consulting fees from St. Jude Medical, Boston Scientific, Medtronic, CathRx, Pacemate, and Microport.

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Authors and Affiliations

  1. Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, 1430 Tulane Avenue, Box 8548, New Orleans, LA, 70112, USA

    Yan Zhao, Vinay Krupadev, Lilas Dagher & Nassir F. Marrouche

  2. Department of Cardiology Klinikum Coburg, Coburg, Germany

    Christian Mahnkopf & Johannes Brachmann

  3. Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany

    Christian Sohns

  4. Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Susanne Sehner, Anna Suling & Karl Wegscheider

  5. Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia

    Prashanthan Sanders

  6. Department of Cardiology, Antonius Ziekenhuis Nieuwegein, Nieuwegein, and Amsterdam UMC, Amsterdam, Netherlands

    Luca Boersma

  7. Department of Cardiology, Deutsches Herzzentrum München, Technical University Munich, Munich, Germany

    Heribert Schunkert

  8. DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany

    Heribert Schunkert

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  1. Yan Zhao
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  2. Vinay Krupadev
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Correspondence to Nassir F. Marrouche.

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Zhao, Y., Krupadev, V., Dagher, L. et al. Pharmacological rhythm versus rate control in patients with atrial fibrillation and heart failure: the CASTLE-AF trial. J Interv Card Electrophysiol 61, 609–615 (2021). https://doi.org/10.1007/s10840-020-00856-1

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