Early Rhythm Control for Atrial Fibrillation in Patients With End-Stage or Chronic Kidney Disease

To investigate the benefits and risks of early rhythm control (ERC) in patients with atrial fibrillation (AF) and chronic kidney disease (CKD).

This population-based cohort study included 5224 patients with AF (58.2% male, median age 70 years) with end-stage kidney disease (ESKD; n=1660) and CKD stage 3 to 4 (n=3564), who underwent ERC or rate control between January 1, 2005, and December 31, 2015. A primary outcome consisted of cardiovascular death, ischemic stroke, heart failure-related hospitalization, and acute myocardial infarction.

During a median follow-up of 3.5 years, compared with rate control, ERC was associated with a reduced risk of the primary outcome (hazard ratio [HR], 0.85; 95% CI, 0.74 to 0.98) without an increase in the composite safety outcome in CKD stage 3 to 4 (HR, 0.99; 95% CI, 0.86 to 1.13). In patients with ESKD, there was no difference between rate control and ERC in the primary outcome (HR, 0.97; 95% CI, 0.81 to 1.17) but an increase in composite safety outcome (HR, 1.29; 95% CI, 1.11 to 1.50). During follow-up, 65.0% of patients with ESKD and 57.3% with CKD stage 3 to 4 failed to maintain ERC. In the on-treatment (HR, 0.79; 95% CI, 0.62 to 0.99) and time-varying regression (HR, 0.81; 95% CI, 0.68 to 0.98) analyses, ERC was associated with a lower risk of primary outcome even in patients with ESKD.

Early rhythm control revealed a modest risk-benefit profile in patients with ESKD compared with CKD stage 3 to 4, with poor adherence to ERC playing a major role. Therefore, an approach tailored to renal function should be considered for choosing AF treatment strategies.