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

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, associated with substantial morbidity and mortality. Although early rhythm control has demonstrated benefit in selected trial populations, its real-world effectiveness remains uncertain.

We conducted a retrospective multicenter cohort study using the TriNetX Global Collaborative Network. Adults (≥ 65 years) with newly diagnosed AF between 2005 and 2025 were included. Patients initiating rhythm control within 1 month of diagnosis were propensity score-matched 1:1 with rate control patients. The primary outcome was 1-year all-cause mortality. Secondary outcomes included thromboembolism, major bleeding, hospitalization, ventricular arrhythmia, cardiac arrest, syncope, AF recurrence, and cardioversion. Subgroup analyses evaluated modality-specific rhythm control, contemporary era, and age-stratified outcomes.

After matching, 200 631 patients were included in each group with balanced baseline characteristics. At 1 year, all-cause mortality was higher with rhythm control than rate control (HR 1.20, 95% CI 1.18-1.22; p < 0.001). Rhythm control demonstrated higher rates of ventricular arrhythmia, cardiac arrest, hospitalization, syncope, and cardioversion, while thromboembolic events and major bleeding occurred less frequently. Substantial heterogeneity emerged by modality. Pharmacologic-only subgroup revealed findings consistent with principal analysis, whereas procedural rhythm control showed lower mortality (HR 0.20, 95% CI 0.16-0.25) and hospitalization.

Among older adults with newly diagnosed AF, early rhythm control was associated with higher mortality and arrhythmic complications versus rate control. Pharmacologic rhythm control largely drove excess mortality, whereas procedural approaches were linked to lower mortality and hospitalization. These findings underscore the importance of careful patient selection when considering early rhythm control strategies in older populations.