Key result
Rate control medication is linked to ~8% lower MACE beyond DOAC therapy alone.
Why the study?
The 2024 ESC Guidelines for AF recommend rate control primarily for symptom management or preventing tachycardia-induced cardiomyopathy. Whether concurrent rate control therapy confers additional prognostic benefit for MACE beyond anticoagulation alone in the contemporary DOAC era remains uncertain.
Does concurrent rate control therapy reduce major adverse cardiovascular events beyond DOAC anticoagulation alone in patients with atrial fibrillation?
Cohort (n=84,817)
Yes
Does concurrent rate control therapy reduce major adverse cardiovascular events beyond DOAC anticoagulation alone in patients with atrial fibrillation?
In a large real-world cohort of patients with atrial fibrillation, concurrent rate-control therapy was independently associated with a lower risk of MACE beyond DOAC anticoagulation alone, suggesting potential prognostic benefit beyond symptom management.
Answers are grounded in this paper and cite their sources.
Rate control was associated with lower MACE beyond DOACs in AF; hypothesis-generating and should not yet change practice.
Background The 2024 ESC Guidelines for atrial fibrillation emphasise anticoagulation for stroke prevention and recommend rate control primarily for symptom management or prevention of tachycardia-induced cardiomyopathy. Whether rate control therapy confers additional prognostic benefit in anticoagulated patients remains uncertain. Purpose To test the hypothesis that in the contemporary DOAC era, concurrent rate control therapy would be independently associated with lower major adverse cardiovascular events (MACE) beyond anticoagulation alone. Methods We conducted a retrospective cohort study using electronic health record data from Clalit Health Services, including all patients with a diagnosis of AF since 2014. The primary outcome was a composite MACE (cardiovascular death, myocardial infarction, ischaemic stroke). DOAC and rate control medication use were treated as time-varying exposures in Cox proportional hazards models. Models were adjusted for age, sex, socioeconomic status, baseline blood pressure and lipid levels, heart failure, chronic kidney disease, diabetes, hypertension, malignancy, prior stroke, and peripheral vascular disease. Results 84,817 patients met the inclusion criteria. DOAC therapy was independently associated with reduced MACE (adjusted HR 0.78; 95% CI 0.74–0.81; P < 0.001). Rate control medication use was independently associated with lower MACE (HR 0.92; 95% CI 0.88–0.97; P < 0.05). Conclusions In this large, real-world AF cohort treated in the DOAC era, rate-control therapy was associated with lower MACE than anticoagulation alone. These findings raise the question of whether rate-control strategies may confer prognostic benefit in selected patients, a hypothesis that warrants prospective evaluation.
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Arbel et al. (2026) conducted a cohort in Atrial fibrillation (n=84,817). Concurrent rate control medication and DOAC therapy vs. Anticoagulation alone / non-use was evaluated on Composite major adverse cardiovascular events (MACE: cardiovascular death, myocardial infarction, ischaemic stroke) (HR 0.92, 95% CI 0.88-0.97, p=<0.05). Rate control medication use was independently associated with lower MACE (HR 0.92; 95% CI 0.88-0.97; P<0.05) beyond DOAC therapy (HR 0.78; 95% CI 0.74-0.81).
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