Why the study?
Although the AFFIRM study demonstrated that AF can be treated effectively with rate control and anticoagulation, drug efficacy to control rate remained uncertain.
Does the choice of rate-controlling drug class affect the efficacy of rate control in patients with atrial fibrillation?
RCT (n=2,027)
randomized
Does the choice of rate-controlling drug class affect the efficacy of rate control in patients with atrial fibrillation?
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“This study has important implications for treatment. It appears that the preferred therapy for many patients with atrial fibrillation may be a strategy to control the heart rate.”
“The AFFIRM study has profound implications for the management of atrial fibrillation. For many physicians it should fundamentally alter their approach to treatment.”
“The rate control approach may also be less costly due to a difference in the number of hospitalizations. We found that patients in the rhythm control group were more likely to be hospitalized, and hospital costs account for the majority of total medical costs.”
Beta-blockers are the most effective first-line agents for achieving rate control in atrial fibrillation, though frequent medication changes and combinations are often required.
OBJECTIVES: We sought to evaluate approaches used to control rate, the effectiveness of rate control, and switches from one drug class to another in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. BACKGROUND: The AFFIRM study showed that atrial fibrillation (AF) can be treated effectively with rate control and anticoagulation, but drug efficacy to control rate remains uncertain. METHODS: Patients (n = 2,027) randomized to rate control in the AFFIRM study were given rate-controlling drugs by their treating physicians. Standardized rate-control efficacy criteria developed a priori included resting heart rate and 6-min walk tests and/or ambulatory electrocardiographic results. RESULTS: Average follow-up was 3.5 +/- 1.3 years. Initial treatment included a beta-adrenergic blocker (beta-blocker) alone in 24%, a calcium channel blocker alone in 17%, digoxin alone in 16%, a beta-blocker and digoxin in 14%, or a calcium channel blocker and digoxin in 14% of patients. Overall rate control was achieved in 70% of patients given beta-blockers as the first drug (with or without digoxin), 54% with calcium channel blockers (with or without digoxin), and 58% with digoxin alone. Adequate overall rate control was achieved in 58% of patients with the first drug or combination. Multivariate analysis revealed an association between first drug class and several clinical variables. There were more changes to beta-blockers than to the other two-drug classes (p < 0.0001). CONCLUSIONS: Rate control in AF is possible in the majority of patients with AF. Beta-blockers were the most effective drugs. To achieve the goal of adequate rate control in all patients, frequent medication changes and drug combinations were needed.
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Olshansky et al. (2004) conducted an RCT in Atrial fibrillation (n=2,027). Beta-blockers vs. Calcium channel blockers or digoxin was evaluated on Overall rate control (resting heart rate and 6-min walk tests and/or ambulatory electrocardiographic results).
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