Rhythm Versus Rate Control Therapy and Subsequent Stroke or Transient Ischemic Attack in Patients With Atrial Fibrillation

Abstract

Background-Stroke is a debilitating condition with an increased risk in patients with atrial fibrillation. Although data from clinical trials suggest that both rate and rhythm control are acceptable approaches with comparable rates of mortality in the short term, it is unclear whether stroke rates differ between patients who filled prescriptions for rhythm or rate control therapy. Methods and Results-We conducted a population-based observational study of Quebec patients Ն65 years with a diagnosis of atrial fibrillation during the period 1999 to 2007 with the use of linked administrative data from hospital discharge and prescription drug claims databases. We compared rates of stroke or transient ischemic attack (TIA) among patients using rhythm (class Ia, Ic, and III antiarrhythmics), versus rate control (␤-blockers, calcium channel blockers, and digoxin) treatment strategies (either current or new users). The cohort consisted of 16 325 patients who filled a prescription for rhythm control therapy (with or without rate control therapy) and 41 193 patients who filled a prescription for rate control therapy, with a mean follow-up of 2.8 years (maximum 8.2 years). A lower proportion of patients on rhythm control therapy than on rate control therapy had a CHADS 2 (congestive heart failure, hypertension, age Ն75 years, diabetes mellitus, and previous stroke or TIA) score of Ն2 (58.1% versus 67.0%, PϽ0.001). Treatment with any antithrombotic drug was comparable in the 2 groups (76.8% in rhythm control versus 77.8% in rate control group). Crude stroke/TIA incidence rate was lower in patients treated with rhythm control in comparison with rate control therapy (1.74 versus 2.49, per 100 person-years, PϽ0.001). This association was more marked in patients in the moderate-and high-risk groups for stroke according to the CHADS 2 risk score.In multivariable Cox regression analysis, rhythm control therapy was associated with a lower risk of stroke/TIA in comparison with rate control therapy (adjusted hazard ratio, 0.80; 95% confidence interval, 0.74, 0.87). The lower stroke/TIA rate was confirmed in a propensity score-matched cohort. Conclusions-In comparison with rate control therapy, the use of rhythm control therapy was associated with lower rates of stroke/TIA among patients with atrial fibrillation, in particular, among those with moderate and high risk of stroke.

Economic Evaluation of Percutaneous Left Atrial Appendage Occlusion, Dabigatran, and Warfarin for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation

“…9 The prevalence of stroke risk factors in the study population was similar to that reported in the RE-LY 4 and PROTECT AF 7 studies, as well as the general Canadian population. 10 The prevalence and incidence of patient comorbidities in the study population, including diabetes mellitus, hypertension, coronary artery and cerebrovascular disease, heart failure, liver disease, renal disease, alcohol consumption, and prior bleeding, were incorporated into the model given their impact on current and subsequent stroke and bleed risk (Table 1). 1,9,[11][12][13] …”

Effect of catheter ablation versus antiarrhythmic drugs on atrial fibrillation: A meta-analysis of randomized controlled trials

“…Restoration of a sinus rhythm is considered to improve the long-term survival rates and reduce the incidence of stroke/TIA in general AF patients (22,23). In addition, a previous observational study indicated that catheter ablation is superior to AADs in reducing the all-cause mortality rate (24).…”

Novel Scoring System for Distinction Between Paroxysmal and Non-Paroxysmal Atrial Fibrillation

“…23 They found that the stroke risk was significantly lower in the rhythm control group than in the rate control group, and such a tendency was more prominent in patients with CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and previous stroke) >1. With regard to stroke risk, distinction of AF patients in whom rhythm control is more effective, is an important issue.…”