What is the clinical evidence from this study?

Study design: Cohort. Population: Acute decompensated heart failure and atrial fibrillation (n=187). Intervention: Early rhythm control vs. Usual care. Primary outcome: All-cause mortality (HR 0.51, 95% CI 0.27-0.93, p=0.029).

What does this research mean for the field?

Early rhythm control in patients with atrial fibrillation and acute heart failure reduces all-cause mortality by 49% compared to usual care over a median follow-up of 2.67 years. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

What question did this study set out to answer?

This study investigates the impact of early rhythm control on outcomes in patients with acute heart failure, specifically focusing on predictors and success rates.

February 6, 2026

Early rhythm control in patients with acute decompensated heart failure

Key Result

Early rhythm control was associated with lower all-cause mortality versus usual care in patients with acute decompensated heart failure and atrial fibrillation (HR 0.51; 95% CI 0.27-0.93; p=0.029).

Key Points

This study investigates the impact of early rhythm control on outcomes in patients with acute heart failure, specifically focusing on predictors and success rates.
Data from a prospective cohort study (CYCLE) with patients hospitalized for acute heart failure were analyzed.
Patients were followed from 2019 until July 2024 to assess rhythm control therapy.
Multivariable logistic regression identified predictors for early rhythm control initiation and success.
Cox regression analysis examined associations between treatment strategies and all-cause mortality.
Among 370 acute heart failure patients, 50.5% had atrial fibrillation (AF).
Early rhythm control was initiated in 21.9% of patients, while the remaining received usual care.
Successful early rhythm control was significantly associated with higher baseline heart rate and new-onset heart failure.
Over a median follow-up of 2.67 years, early rhythm control correlated with lower all-cause mortality (HR: 0.51).
Successful rhythm control was linked to even lower mortality (HR: 0.25) during follow-up.

Study Design

Type

Cohort (n=187)

Structured PICO

Does early rhythm control reduce all-cause mortality in patients with acute decompensated heart failure and atrial fibrillation?

Population

187 patients with acute decompensated heart failure (AHF) and atrial fibrillation (AF) from a prospective cohort of 370 AHF patients. Median age 76 years, 69.4% men.

Intervention

Early rhythm control therapy (cardioversion, antiarrhythmic drugs including amiodarone, dronedarone, flecainide, or propafenone, or AF ablation)

Comparator

Usual care

Outcome

All-cause mortalityhard clinical

In patients with acute decompensated heart failure and atrial fibrillation, early rhythm control is associated with significantly lower all-cause mortality compared to usual care.

Main Result

Effect estimate: HR 0.51 (95% CI 0.27-0.93)

p-value: p=0.029

Abstract

Abstract Background Early rhythm control improves outcomes in patients with atrial fibrillation (AF) and heart failure. The role of rhythm control in acute heart failure (AHF) remains uncertain. Purpose This study aimed to assess patient characteristics, independent predictors of decision for early rhythm control and its success, and associations between treatment strategies and outcomes in patients with AHF. Methods This analysis used data from a prospective cohort study (CYCLE) enrolling consecutive patients with new or worsening heart failure. All patients were enrolled from 2019 and followed until July 2024. Rhythm control therapy was defined as cardioversion, use of antiarrhythmic drugs (amiodarone, dronedarone, flecainide, or propafenone) or AF ablation. Rhythm control success was defined by a sinus rhythm in the electrocardiogram at discharge. Multivariable logistic regression was used to identify independent predictors for early rhythm control initiation and its success during the AHF episode. Cox regression analysis was performed to assess associations between treatment strategies and all-cause mortality. Results Among 370 patients hospitalised due to AHF, 187 (50.5%) had AF. AHF patients with AF were older (median 76 years; 69.4% men) than patients with AHF without AF (median 70 years; 69.0% men). Early rhythm control was used in 41 (21.9%) patients, 146 (78.1%) received usual care. Independent predictors of early rhythm control included higher baseline heart rate (odds ratio OR per standard deviation SD: 1.78 1.28-2.54) and new-onset heart failure (OR per SD: 1.59 1.16-2.19). Lower likelihood of choosing early rhythm control was observed in those with coronary artery disease (CAD) (OR per SD: 0.59 0.41-0.84), ischemic cardiomyopathy (OR per SD: 0.59 0.39-0.85), anaemia (OR per SD: 0.58 0.40-0.83), beta-blocker use (OR per SD: 0.73 0.54-1.00), and statin use (OR per SD: 0.70 0.49-0.99). Successful early rhythm control was independently associated with higher baseline heart rate (OR per SD: 1.79 1.22-2.66), new-onset heart failure (OR per SD: 1.54 1.08-2.19), and with amiodarone loading (OR per SD: 4.41 2.91-7.38). Contrarily, a lower likelihood of successful early rhythm control was seen in patients with CAD (OR per SD: 0.47 0.30-0.74), ischemic cardiomyopathy (OR per SD: 0.55 0.34-0.89), and beta-blocker use (OR per SD: 0.69 0.49-1.00). Over a median follow-up of 2.67 years (95% CI 2.09-3.85), early rhythm control was associated with a lower all-cause mortality (hazard ratio HR: 0.51 0.27-0.93; p=0.029) in patients with AF and AHF (Figure 1A). Similarly, over a median follow-up of 2.57 years (95% CI 1.73-4.43), successful early rhythm control was associated with lower all-cause mortality (HR: 0.25 0.09-0.69; p=0.0073) (Figure 1B). Conclusion These hypothesis-generating results support the evaluation of early rhythm control for outcome reduction in patients with AHF and AF.

Bookmark