Relationships Between Sinus Rhythm, Treatment, and Survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study

Abstract

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

Prognostic Significance of Resting Heart Rate and Use of β-Blockers in Atrial Fibrillation and Sinus Rhythm in Patients With Heart Failure and Reduced Ejection Fraction

“…The prognostic significance of AF in patients with HF is inconsistent in the literature. In some studies, AF was associated with increased long-term mortality and the occurrence of adverse cardiovascular events in patients with HFrEF, [16][17][18] but here, AF may have been a marker of risk rather than risk factor. In other studies, only HF patients with new-onset AF, not those with preexisting AF, had an increased risk of death.…”

Successful recovery of tachycardia‐induced cardiomyopathy with severely depressed left ventricular systolic function by catheter ablation with mechanical hemodynamic support: a case report

“…In the AFFIRM study, treatment of patients with AF using rhythm control offered no survival advantage over rate control 10. However, the substudy of the AFFIRM study showed that restoration and maintenance of SR were associated with a lower risk of death and that the use of antiarrhythmic drugs was associated with increased mortality 11. Additionally, rhythm control by PVI is superior to rate control in terms of sinus node function, LA pressure, and LVEF recovery 5.…”

Cardioembolic Stroke: Call for a Multidisciplinary Approach

“…Nevertheless, the use of drugs led to an increase in mortality after adjustment by sinus rhythm (HR 1.49, 95% CI 1.11–2.01, p < 0.0005), which was probably related to their adverse effects. Therefore, the greatest benefit would be achieved if a method for maintenance of sinus rhythm without or little undesirable effects were found [16, 17]. These results can be explained by the short average of electrical cardioversion made in rhythm control, the small number of antiarrhythmic drugs tested (1.5/patient), the smaller average of anticoagulation therapy in the rhythm control approach (70%) than in rate control (90%), and because a great number of patients in the latter strategy were in sinus rhythm at the moment of randomization since they had AF paroxysms or recent cardioversions.…”