Rhythm Versus Rate Control Therapy and Subsequent Stroke or Transient Ischemic Attack in Patients With Atrial Fibrillation
Background—Stroke is a debilitating condition with an increased risk in patients with atrial fibrillation (AF). While data from clinical trials suggest that both rate and rhythm control are acceptable approaches with comparable rates of mortality in the short term, it is unclear whether stroke rates differ between patients who filled prescriptions for rhythm or rate control therapy.
Methods and Results—We conducted a population-based observational study of Quebec patients ≥65 years with a diagnosis of AF during the period 1999 to 2007, using linked administrative data from hospital discharge and prescription drug claims databases. We compared rates of stroke or transient ischemic attack (TIA) among patients using rhythm (class Ia, Ic, and Class III antiarrhythmics), versus rate control (beta-blockers, calcium channel blockers and digoxin) treatment strategies (either current or new users). The cohort consisted of 16,325 patients who filled a prescription for rhythm control therapy (with or without rate control therapy) and 41,193 patients who filled a prescription for rate control therapy, with a mean follow up of 2.8 years (maximum 8.2 years). A lower proportion of patients on rhythm control therapy than on rate control therapy had a CHADS2 score of ≥2 (58.1% vs. 67.0%, p<0.001). Treatment with any antithrombotic drug was comparable in the two groups (76.8% in rhythm control vs. 77.8% in rate control group). Crude stroke/TIA incidence rate was lower in patients treated with rhythm control compared to rate control therapy (1.74 vs. 2.49, per 100 person-years, p-value<0.001). This association was more marked in patients in the moderate and high risk groups for stroke according to the CHADS2 risk score. In multivariable Cox regression analysis, rhythm control therapy was associated with a lower risk of stroke/TIA compared with rate control therapy (adjusted HR 0.80, 95% CI: 0.74, 0.87). The lower stroke/TIA rate was confirmed in a propensity score matched cohort.
Conclusions—Compared with rate control therapy, the use of rhythm control therapy was associated with lower rates of stroke/TIA among patients with AF, particularly among those with moderate and high risk of stroke.
- Received January 11, 2012.
- Accepted October 22, 2012.
- Copyright © 2012, American Heart Association, Inc. All rights reserved. Unauthorized use prohibited