Early Rhythm Versus Rate Control in Older Adults With New-Onset Atrial Fibrillation: A Propensity Score-Matched...

Area of Science:

• Cardiology
• Geriatrics
• Public Health

Background:

• Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, contributing significantly to morbidity and mortality.
• While early rhythm control shows benefits in specific trial groups, its real-world effectiveness in older adults remains unclear.

Purpose of the Study:

• To evaluate the real-world effectiveness of early rhythm control versus rate control for newly diagnosed atrial fibrillation in older adults (≥65 years).
• To compare 1-year all-cause mortality and secondary outcomes, including thromboembolism, bleeding, and hospitalization, between the two strategies.

Main Methods:

• Retrospective multicenter cohort study using the TriNetX Global Collaborative Network.
• Inclusion of adults (≥65 years) with newly diagnosed AF between 2005 and 2025.
• Propensity score matching (1:1) of patients initiating rhythm control within 1 month of diagnosis with rate control patients.

Main Results:

• Early rhythm control was associated with higher 1-year all-cause mortality (HR 1.20) compared to rate control in 200,631 matched patients per group.
• Rhythm control showed increased ventricular arrhythmia, cardiac arrest, hospitalization, syncope, and cardioversion, but decreased thromboembolism and major bleeding.
• Procedural rhythm control demonstrated significantly lower mortality (HR 0.20) and hospitalization, while pharmacologic rhythm control was linked to excess mortality.

Conclusions:

• In older adults with new-onset AF, early rhythm control is linked to increased mortality and arrhythmic complications versus rate control.
• Pharmacologic rhythm control strategies appear to drive the excess mortality observed in the overall rhythm control group.
• Procedural rhythm control approaches show promise with lower mortality and hospitalization rates, emphasizing the critical role of patient selection.