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Clinical Outcomes of Rate vs Rhythm Control for Atrial Fibrillation in Older People: A Systematic Review and Meta-Analysis

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Abstract

Background and Objectives

Atrial fibrillation (AF) is highly prevalent in older adults and has been associated with increased morbidity and mortality. To reduce this AF-related morbidity in older adults, antiarrhythmic drugs (AADs) are regularly used for rhythm control, assuming that increasing time in sinus rhythm reduces AF-related morbidity. However, whether AADs can improve clinical outcomes in older adults remains unclear because of the increased risk for adverse drug events compared with rate control. The aim of this study was to determine the impact of rhythm control versus rate control on clinical outcomes in older adults with AF.

Design and Methods

We conducted a systematic review and meta-analysis targeting patients aged ≥65 years with AF and using drugs to control rate or rhythm. Articles that met the following criteria were included: enrolled older patients (sample mean ≥75 years) with AF, compared pharmacological rate versus rhythm control, and reported all-cause mortality, cardiovascular mortality, or ischemic stroke.

Results

Five observational studies were included. In total, 86,926 patients with AF with a mean age ranging from 75 to 92 years were studied. No differences were found between rhythm and rate control for all-cause mortality (odds ratio [OR] 1.11; 95% confidence interval [CI] 0.78–1.59; I2 = 79.6%; n = 28,526; four studies) and cardiovascular mortality (OR 1.09; 95% CI 0.81–1.47; I2 = 0%; n = 2292; two studies). Rhythm control resulted in fewer strokes (OR 0.86; 95% CI 0.80–0.93; I2 = 0%; n = 59,496), although this was mainly determined by one study.

Conclusion

All collected data were observational, which precluded making strong recommendations. Furthermore, all CIs were wide, increasing the uncertainty of the observed effects. As such, evidence was insufficient to recommend rhythm or rate control as the first-line therapy for AF in older adults. As AF is particularly prevalent in older people, more randomized controlled trials are needed in this population.

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References

  1. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults. JAMA. 2001;285(18):2370–5.

    Article  CAS  Google Scholar 

  2. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke. 1991;22:983–9.

    Article  CAS  Google Scholar 

  3. Mavaddat N, Roalfe A, Fletcher K, et al. Warfarin versus aspirin for prevention of cognitive decline in atrial fibrillation: randomized controlled trial (Birmingham Atrial Fibrillation Treatment of the Aged Study). Stroke. 2014;45(5):1381–6.

    Article  CAS  Google Scholar 

  4. Healey JS, Oldgren J, Ezekowitz M, et al. Occurrence of death and stroke in patients in 47 countries 1 year after presenting with atrial fibrillation: a cohort study. Lancet. 2016;388(10050):1161–9.

    Article  Google Scholar 

  5. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur. Heart J. 2016;37(38):2893–962.

    Article  Google Scholar 

  6. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130(23):2071–104.

    Article  Google Scholar 

  7. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146(12):857–67.

    Article  Google Scholar 

  8. Hylek EM, Go AS, Chang Y, et al. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med. 2003;349(11):1579–2158158.

    Article  Google Scholar 

  9. Caldeira D, David C, Sampaio C. Rate versus rhythm control in atrial fibrillation and clinical outcomes: updated systematic review and meta-analysis of randomized controlled trials. Arch Cardiovasc Dis. 2012;105(4):226–38.

    Article  Google Scholar 

  10. Sethi NJ, Feinberg J, Nielsen EE, et al. The effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter: a systematic review with meta-analysis and trial sequential analysis. PLoS O ne. 2017;12(10):1–28.

    Google Scholar 

  11. Slim K, Nini E, Forestier D, et al. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–6.

    Article  Google Scholar 

  12. Shariff N, Desai RV, Patel K, et al. Rate-control versus rhythm-control strategies and outcomes in septuagenarians with atrial fibrillation. Am J Med. 2013;126(10):887–93.

    Article  Google Scholar 

  13. Wutzler A, von Ulmenstein S, Attanasio P, et al. Treatment of nonagenarians with atrial fibrillation: insights from the Berlin atrial fibrillation (BAF) registry. J Am Med Dir Assoc. 2015;16(11):969–72.

    Article  Google Scholar 

  14. Paciullo F, Proietti M, Bianconi V, et al. Choice and outcomes of rate control versus rhythm control in elderly patients with atrial fibrillation: a report from the REPOSI study. Drugs Aging. 2018;35(4):365–73.

    Article  CAS  Google Scholar 

  15. Ionescu-Ittu R, Abrahamowicz M, Jackevicius CA, et al. Comparative effectiveness of rhythm control vs rate control drug treatment effect on mortality in patients with atrial fibrillation. Arch Intern Med. 2012;172(13):997–1004.

    Article  Google Scholar 

  16. Tsadok MA, Jackevicius CA, Essebag V, et al. Rhythm versus rate control therapy and subsequent stroke or transient ischemic attack in patients with atrial fibrillation. Circulation. 2012;126(23):2680–7.

    Article  Google Scholar 

  17. Tavernier R, Wolf M, Kataria V, et al. Screening for atrial fibrillation in hospitalised geriatric patients. Heart. 2018;104(7):588–93.

    Article  Google Scholar 

  18. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347(23):1825–33.

    Article  CAS  Google Scholar 

  19. Van Gelder IC, Hagens VE, Bosker HA, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med. 2002;347(23):1834–40.

    Article  Google Scholar 

  20. Roy D, Talajic M, Nattel S, et al. Rythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358(25):1315–23.

    Article  Google Scholar 

  21. Carlsson J, Miketic S, Windeler J, et al. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the strategies of treatment of atrial fibrillation (STAF) study. J Am Coll Cardiol. 2003;41(10):1690–6.

    Article  Google Scholar 

  22. Camm AJ, Breithardt G, Crijns H, et al. Real-life observations of clinical outcomes with rhythm- and rate-control therapies for atrial fibrillation: RECORDAF (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation). J Am Coll Cardiol. 2011;58(5):493–501.

    Article  Google Scholar 

  23. Noheria A, Shrader P, Piccini JP, et al. Rhythm control versus rate control and clinical outcomes in patients with atrial fibrillation: results from the ORBIT-AF registry. JACC Clin Electrophysiol. 2016;2(2):221–9.

    Article  Google Scholar 

  24. Albina G, De Luca J, Conde D, et al. Atrial fibrillation: an observational study with outpatients. Pacing Clin Electrophysiol. 2014;37(11):1485–91.

    Article  Google Scholar 

  25. Ayan M, Pothineni NV, Siraj A, et al. Cardiac drug therapy-considerations in the elderly. J Geriatr Cardiol. 2016;13(12):992–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  26. Shelton RJ, Clark AL, Goode K, et al. A randomised, controlled study of rate versus rhythm control in patients with chronic atrial fibrillation and heart failure: (CAFÉ-II study). Heart. 2009;95(11):924–30.

    Article  CAS  Google Scholar 

  27. Ha AC, Breithardt G, Camm AJ, et al. Health-related quality of life in patients with atrial fibrillation treated with rhythm control versus rate control: insights from a prospective international registry (registry on cardiac rhythm disorders assessing the control of atrial fibrillation: RECORD-AF). Circ Cardiovasc Qual Outcomes. 2014;7(6):896–904.

    Article  Google Scholar 

  28. Hagens VE, Ranchor AV, Van Sonderen E, et al. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation: results from the rate control versus electrical cardioversion (RACE) study. J Am Coll Cardiol. 2004;43(2):241–7.

    Article  Google Scholar 

  29. Jenkins LS, Brodsky M, Schron E, et al. Quality of life in atrial fibrillation: the atrial fibrillation follow-up investigation of rhythm management (AFFIRM) study. Am Heart J. 2005;149(1):112–20.

    Article  Google Scholar 

  30. Roy D, Talajic M, Dorian P, et al. Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators. N Engl J Med. 2000;342(13):913–20.

    Article  CAS  Google Scholar 

  31. Mannucci PM, Nobili A, Pasina L, et al. Polypharmacy in older people: lessons from 10 years of experience with the REPOSI register. Intern Emerg Med. 2018;13(8):1191–200.

    Article  Google Scholar 

  32. Franchi C, Antoniazzi S, Proietti M, et al. Appropationess of oral anticoagulation therapy prescription and its associated factors in hospitalized older people with atrial fibrillation. Br J Clin Pharmacol. 2018;84(9):2010–9.

    Article  Google Scholar 

Download references

Author information

Author notes

  1. Joint first authorship: Laurence Depoorter and Liza Sels.

Authors and Affiliations

  1. Geriatric Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium

    Laurence Depoorter, Liza Sels & Jos Tournoy

  2. Gerontology and Geriatrics, Department of Chronic Diseases, Metabolism and Ageing, KU Leuven-University of Leuven, Herestraat 49, 3000, Leuven, Belgium

    Mieke Deschodt & Jos Tournoy

  3. Nursing Science, Department of Public Health, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland

    Mieke Deschodt

  4. Research Foundation Flanders, Brussels, Belgium

    Bastiaan Van Grootven

  5. Department of Public Health and Primary Care, KU Leuven-University of Leuven, Leuven, Belgium

    Bastiaan Van Grootven

  6. Pharmacy Department, University Hospitals Leuven, Leuven, Belgium

    Lorenz Van der Linden

  7. Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium

    Lorenz Van der Linden

Authors
  1. Laurence Depoorter
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  2. Liza Sels
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  3. Mieke Deschodt
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  4. Bastiaan Van Grootven
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  5. Lorenz Van der Linden
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  6. Jos Tournoy
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Corresponding author

Correspondence to Jos Tournoy.

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Funding

No external funding was used in the preparation of this manuscript.

Conflict of interest

L. Depoorter, L. Sels, M. Deschodt, and B. Van Grootven have no potential conflicts of interest that might be relevant to the contents of this manuscript. L. Van der Linden and J. Tournoy have received lecture or consulting fees from Pfizer, Bristol-Meyers Squibb, Bayer, and Daichii Sankyo.

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Depoorter, L., Sels, L., Deschodt, M. et al. Clinical Outcomes of Rate vs Rhythm Control for Atrial Fibrillation in Older People: A Systematic Review and Meta-Analysis. Drugs Aging 37, 19–26 (2020). https://doi.org/10.1007/s40266-019-00722-4

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  • DOI: https://doi.org/10.1007/s40266-019-00722-4

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