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Published on: February 26, 2013
Rhythm control versus rate control in patients with persistent atrial fibrillation. Results of the HOT CAFE Polish
Grzegorz Opolski1, Adam Torbicki, Dariusz Kosior
1Chair and Department of Internal Medicine and Cardiology, Medical Academy, Warsaw, Poland.
Insights
Rate control and rhythm control strategies for atrial fibrillation (AF) showed similar mortality rates. Rhythm control led to more hospitalizations and strokes, despite some hemodynamic benefits.
Area of Science:
- Cardiology
- Clinical Medicine
- Pharmacology
Background:
- Atrial fibrillation (AF) management involves either maintaining sinus rhythm (SR) or controlling ventricular rate.
- The superiority of rate control versus rhythm control in persistent AF remains unclear.
Purpose of the Study:
- To compare the risks and benefits of rate control versus rhythm control strategies in patients with persistent AF.
- The HOT CAFE Polish Study aimed to evaluate these two therapeutic approaches.
Main Methods:
- A randomized, multicenter study involving 205 patients with persistent AF.
- Patients were assigned to either rate control (Group I) or SR restoration via cardioversion and antiarrhythmic drugs (Group II).
- Follow-up was conducted over 12 months.
Main Results:
- Higher hospital admission rates were observed in the SR restoration group (74%) compared to the rate control group (12%).
- Mortality rates were similar between groups (1.0% vs 2.9%).
- Improved heart failure symptoms and exercise tolerance were noted in the SR group, alongside enhanced left ventricular function.
Conclusions:
- No significant difference in mortality between rate control and rhythm control for persistent AF.
- Rhythm control resulted in higher hospitalization rates and similar stroke incidence compared to rate control.
- Despite hemodynamic improvements, rhythm control did not reduce stroke risk and increased hospital admissions.
Background:
Patients with atrial fibrillation (AF) can be managed either by maintaining sinus rhythm using antiarrhythmic drugs and/or electrical cardioversion, or by leaving patients in AF and controlling ventricular rate without attempts to restore sinus rhythm. Which of these two strategies is superior, has not yet been definitively established.
Aim:
HOT CAFE Polish Study (How To Treat Chronic Atrial Fibrillation) was designed to evaluate in a randomised, multicentre and prospective manner the risks and advantages of two therapeutical strategies - rate control or rhythm control, in patients with persistent AF.
Methods:
The study group consisted of 205 patients (71 females and 134 males; mean age 60.8+/-11.2 years) with a mean time of AF duration of 273.7+/-112.4 days; 101 patients were randomly assigned to rate control (Group I) whereas 104 patients were randomised to sinus rhythm (SR) restoration by DC cardioversion (CV) and subsequent antiarrhythmic drug treatment (Group II). At the end of follow-up (12 months) SR was present in 75% of patients.
Results:
The incidence of hospital admissions was higher in group II in comparison to group I (12% vs 74%; p<0.001). Mortality was similar in both groups (1.0% versus 2.9%, NS). In both groups a significant improvement of heart failure symptoms was observed during the first 2 months (p<0.02 and p<0.001). In group II exercise tolerability measured by maximal workload during treadmill test significantly improved compared with baseline (5.2+/-5.1 vs 7.6+/-3.3 MET; p<0.0001). In patients in whom SR was restored, the left ventricular function improved and an increase in the shortening fraction was observed (29+/-7% vs 31+/-7%; p<0.01). No thromboembolic complications were observed in patients left with AF. Three patients from group II suffered ischaemic stroke; in two cases stroke was associated with CV whereas in the third patient - with late AF recurrence.
Conclusions:
The HOT CAFE Polish Study did not reveal significant differences in mortality between the two treatment strategies in patients with persistent AF. Although patients with SR had better improvement in some haemodynamical parameters, the hospitalisation rate was higher and the incidence of stroke was not reduced compared with the rate control group.
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