The effectiveness and safety of rhythm control for atrial fibrillation in patients with end-stage or chronic kidney disease

Background Although early rhythm control improves cardiovascular outcomes in patients with atrial fibrillation (AF), its use in patients with end-stage renal disease (ESRD) remains challenging. This study aimed to investigate the effectiveness and safety of rhythm control in patients with renal failure, including ESRD. Methods This population-based cohort study included 31,687 patients with AF who underwent rhythm or rate control between 2005 and 2015. Patients were categorized into three groups based on the estimated glomerular filtration rate: ESRD (<15ml/min/1.73m² or undergoing dialysis), 15– 60ml/min/1.73m², and ≥60ml/min/1.73m². The primary outcome consisted of cardiovascular death, ischemic stroke, heart failure-related hospitalization, and acute myocardial infarction. Results Among study population, 20,629 (65.1%) were male patients, with a median age of 63 years and a median follow-up period of 3.6 years. In the ESRD group, the comparative effectiveness of rhythm control was not significant (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.81 to 1.17). However, in the 15–60ml/min/1.73m² group, rhythm control was associated with a lower risk of the primary outcome than rate control (HR 0.85, 95% CI 0.74 to 0.98). This beneficial trend was consistently observed in the ≥60ml/min/1.73m² group (HR 0.87, 95% CI 0.80 to 0.93). No significant interaction was observed between renal function and treatment (p for interaction = 0.172). Rhythm control tended to have a significantly higher risk for the composite safety outcome than rate control in the ESRD group, with a significant renal function-by-treatment interaction (HR 1.29, 95% CI 1.11 to 1.50; p for interaction = 0.016). Conclusion In patients with renal failure, rhythm control was associated with better cardiovascular outcomes than rate control. However, the comparative effectiveness of rhythm control was less prominent in patients with ESRD, and the risk of adverse outcomes was higher than that of rate control. Therefore, rhythm control should be considered selectively in patients with renal failure. Clinical Perspective What is new? Among patients with relatively preserved renal function, rhythm control strategies were associated with a lower risk of primary outcome than rate control strategies. However, this beneficial trend was less prominent in patients with end-stage renal disease (ESRD). In addition, in patients with ESRD, unlike in patients with relatively preserved renal function, rhythm control strategies were significantly associated with a higher risk of composite safety outcome than rate control strategies. What are the clinical implications? Recent major clinical trials have reported that early application of antiarrhythmic agents or catheter ablation in patients with atrial fibrillation can improve cardiovascular outcomes. However, patients with advanced renal failure, including ESRD, were largely excluded from these studies. As a result, the comparative effectiveness of rhythm control strategies could not be generalized to this specific AF population. This nationwide population-based study will assist in identifying appropriate patient selection based on renal function to ensure the benefits of rhythm control strategies.