Pharmacological rhythm versus rate control in patients with atrial fibrillation and heart failure: the CASTLE-AF trial
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Pharmacological rhythm versus rate control in patients with atrial fibrillation and heart failure: the CASTLE-AF trial Yan Zhao 1 & Vinay Krupadev 1 & Lilas Dagher 1 & Christian Mahnkopf 2 & Christian Sohns 3 & Susanne Sehner 4 & Anna Suling 4 & Prashanthan Sanders 5 & Luca Boersma 6 & Heribert Schunkert 7,8 & Karl Wegscheider 4 & Johannes Brachmann 2 & Nassir F. Marrouche 1 Received: 22 July 2020 / Accepted: 24 August 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background The value of antiarrhythmics to maintain normal sinus rhythm in patients with atrial fibrillation (AF) and heart failure (HF) is still being debated. We aimed to determine whether rhythm control using antiarrhythmic drugs (AADs) is more effective than rate control in improving outcomes in this population. Method In this sub-analysis of the CASTLE-AF study, we included patients that were treated pharmacologically either to maintain sinus rhythm or to achieve rate control. The primary endpoint was defined as a composite of death from any cause or worsening of HF that led to an unplanned overnight hospitalization. Result Among 210 patients (mean age of 64.1 ± 10.8 years, 83.3% male) treated pharmacologically, 60 patients were in the rhythm control group and 150 were in the rate control group. Patients in the rhythm control group were less likely to be assigned a beta-blocker (53 (88.3%) vs 141 (97.9%), P = 0.004) and digitalis (8 (13.3%) vs 53 (36.8%), P < 0.001). Over a median followup of 3.76 (95% confidence interval (CI), 3.23, 4.48) years, the primary composite endpoint of all-cause mortality and HF admissions occurred in 23 patients (38.3%) in the rhythm control arm vs 67 (44.7%) in the rate control arm (hazard ratio, 0.99; 95% CI, 0.62 to 1.60; P = 0.976). Conclusion In CASTLE-AF among AF patients with HF, rhythm control with AADs did not significantly reduce the primary composite endpoint of all-cause mortality and HF hospitalization when compared with a pharmacological rate control strategy. Keywords Atrial fibrillation . Heart failure . Rate control . Rhythm control . Antiarrhythmic drugs
* Nassir F. Marrouche [email protected] 1
Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, 1430 Tulane Avenue, Box 8548, New Orleans, LA 70112, USA
2
Department of Cardiology Klinikum Coburg, Coburg, Germany
3
Clinic for Electrophysiology, Herz-und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
4
Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
5
Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
6
Department of Cardiology, Antonius Ziekenhuis Nieuwegein, Nieuwegein, and Amsterdam UMC, Amsterdam, Netherlands
7
Department of Cardiology, Deutsches Herzzentrum München, Technical University Munich, Munich, Germany
8
DZHK (German Centre for Cardiovascular Research), Partner site Muni
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