March 3, 2021EP EuropaceOpen Access

Antiarrhythmic drugs in patients with early persistent atrial fibrillation and heart failure: results of the RACE 3 study

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Why the study?

Maintaining sinus rhythm in persistent AF is challenging, prompting an exploration of class I and III antiarrhythmic drug efficacy in persistent AF and mild to moderate HF.

Does treatment with class I and III antiarrhythmic drugs maintain sinus rhythm in patients with early persistent atrial fibrillation and mild to moderate heart failure?

Structured PICO

Does treatment with class I and III antiarrhythmic drugs maintain sinus rhythm in patients with early persistent atrial fibrillation and mild to moderate heart failure?

Population

245 patients with early persistent symptomatic atrial fibrillation (AF) and short history of mild to moderate heart failure (HF) with preserved or reduced left ventricular ejection fraction (LVEF), mean age 65 ± 9 years, 79% men.

Intervention

Class I and III antiarrhythmic drugs (flecainide, sotalol, dronedarone, amiodarone) instituted for symptomatic recurrent AF.

Comparator

Comparison between different antiarrhythmic drugs (amiodarone vs. flecainide vs. sotalol/dronedarone).

Outcome

Sinus rhythm on 7-day Holter after 1-year.surrogate

In patients with early persistent AF and mild to moderate HF, amiodarone was significantly more effective than flecainide, sotalol, or dronedarone at maintaining sinus rhythm at 1 year, with no serious adverse effects.

Implication

AADs maintained sinus rhythm in nearly half without serious AEs; leaves open their role in early persistent AF with mild HF.

Abstract

AIMS: Maintaining sinus rhythm in patients with persistent atrial fibrillation (AF) is challenging. We explored the efficacy of class I and III antiarrhythmic drugs (AADs) in patients with persistent AF and mild to moderate heart failure (HF). METHODS AND RESULTS: In the RACE 3 trial, patients with early persistent symptomatic AF and short history of mild to moderate HF with preserved or reduced left ventricular ejection fraction (LVEF) were randomized to targeted or conventional therapy. Both groups received AF and HF guideline-driven treatment. Additionally, the targeted-group received mineralocorticoid receptor antagonists, statins, angiotensin-converting enzyme inhibitors and/or receptor blockers, and cardiac rehabilitation. Class I and III AADs could be instituted in case of symptomatic recurrent AF. Eventually, pulmonary vein isolation could be performed. Primary endpoint was sinus rhythm on 7-day Holter after 1-year. Included were 245 patients, age 65 ± 9 years, 193 (79%) men, AF history was 3 (2-6) months, HF history 2 (1-4) months, 72 (29.4%) had HF with reduced LVEF. After baseline electrical cardioversion (ECV), 190 (77.6%) had AF recurrences; 108 (56.8%) received class I/III AADs; 19 (17.6%) flecainide, 36 (33.3%) sotalol, 3 (2.8%) dronedarone, 50 (46.3%) amiodarone. At 1-year 73 of 108 (68.0%) patients were in sinus rhythm, 44 (40.7%) without new AF recurrences. Maintenance of sinus rhythm was significantly better with amiodarone [n = 29/50 (58%)] compared with flecainide [n = 6/19 (32%)] and sotalol/dronedarone [n = 9/39 (23%)], P = 0.0064. Adverse events occurred in 27 (25.0%) patients, were all minor and reversible. CONCLUSION: In stable HF patients with early persistent AF, AAD treatment was effective in nearly half of patients, with no serious adverse effects reported.