Key result
DC cardioversion restores sinus rhythm in ~95% of patients vs rate control, linked to superior survival.
Why the study?
Atrial flutter and fibrillation in pre-capillary pulmonary hypertension are associated with increased morbidity and mortality, but rate and rhythm control strategies have not been directly compared.
Does rhythm control and restoration of sinus rhythm improve survival and functional status compared to rate control in patients with PAH or CTEPH and new-onset atrial flutter or fibrillation?
Cohort (n=84)
Does rhythm control and restoration of sinus rhythm improve survival and functional status compared to rate control in patients with PAH or CTEPH and new-onset atrial flutter or fibrillation?
In patients with PAH or CTEPH and new-onset atrial flutter or fibrillation, restoring sinus rhythm (particularly via DC cardioversion) is associated with significantly improved 3-year survival and functional status compared to rate control.
May support rhythm control in PAH/CTEPH with new AF; leaves open causal benefit pending randomized trials.
BACKGROUND: The development of atrial flutter and fibrillation (AFL/AF) in patients with pre-capillary pulmonary hypertension has been associated with an increased risk of morbidity and mortality. Rate and rhythm control strategies have not been directly compared. METHODS: Eighty-four patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) with new-onset AFL/AF were identified in the ASPIRE registry. First, baseline characteristics and rates of sinus rhythm (SR) restoration of 3 arrhythmia management strategies (rate control, medical rhythm control and DC cardioversion, DCCV) in an early (2009-13) and later (2014-19) cohort were compared. Longer-term outcomes in patients who achieved SR versus those who did not were then explored. RESULTS: Sixty (71%) patients had AFL and 24 (29%) AF. Eighteen (22%) patients underwent rate control, 22 (26%) medical rhythm control and 44 (52%) DCCV. SR was restored in 33% treated by rate control, 59% medical rhythm control and 95% DCCV (p < 0.001). Restoration of SR was associated with greater improvement in functional class (FC) and Incremental Shuttle Walk Distance (p both <0.05). It also independently predicted superior survival (3-year survival 62% vs 23% in those remaining in AFL/AF, p < 0.0001). In addition, FC III/IV independently predicted higher mortality (HR 2.86, p = 0.007). Right atrial area independently predicted AFL/AF recurrence (OR 1.08, p = 0.01). DCCV was generally well tolerated with no immediate major complications. CONCLUSIONS: Restoration of SR is associated with superior functional improvement and survival in PAH/CTEPH compared with rate control. DCCV is generally safe and is more effective than medical therapy at achieving SR.
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Sammut et al. (2022) conducted a cohort in Pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension with new-onset atrial flutter/fibrillation (n=84). DC cardioversion (DCCV) vs. Rate control was evaluated on Restoration of sinus rhythm (p=<0.001). DC cardioversion restored sinus rhythm in 95% of patients versus 33% with rate control (p<0.001), and achieving sinus rhythm was associated with superior 3-year survival (62% vs 23%, p<0.0001).
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