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CLINICAL RESEARCH: ATRIAL FIBRILLATION

The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study

Approaches to control rate in atrial fibrillation

Brian Olshansky, MD, FACC^*,*, Lynda E. Rosenfeld, MD, FACC, Alberta L. Warner, MD, FACC, Allen J. Solomon, MD, FACC, Gearoid O'Neill, MD, FACC^||, Arjun Sharma, MD, FACC^||, Edward Platia, MD, FACC^¶, Gregory K. Feld, MD, FACC^#, Toshio Akiyama, MD, FACC^**, Michael A. Brodsky, MD, FACC, H. Leon Greene, MD, FACC AFFIRM Investigators

^* University of Iowa, Iowa City, Iowa, USA
Yale University School of Medicine, New Haven, Connecticut, USA
West Los Angeles Veterans Administration Medical Center, Los Angeles, California, USA
Georgetown University Medical Center, Washington, DC, USA
^|| Sutter Institute for Medical Research, Sacramento, California, USA
^¶ Washington Hospital Center, Washington, DC, USA
^# University of California, San Diego, California, USA
^** University of Rochester, Rochester, New York, USA
University of California at Irvine, Irvine, California, USA
University of Washington and Axio Research Corporation, Seattle, Washington, USA

Manuscript received August 12, 2003; revised manuscript received October 29, 2003, accepted November 20, 2003.

^* Reprint requests and correspondence: Dr. Brian Olshansky, University of Iowa Hospitals, 200 Hawkins Drive, Iowa City, Iowa 52242, USA.
brian-olshansky{at}uiowa.edu

OBJECTIVES: We sought to evaluate approaches used to control rate, the effectiveness of rate control, and switches from one drug class to another in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study.

BACKGROUND: The AFFIRM study showed that atrial fibrillation (AF) can be treated effectively with rate control and anticoagulation, but drug efficacy to control rate remains uncertain.

METHODS: Patients (n = 2,027) randomized to rate control in the AFFIRM study were given rate-controlling drugs by their treating physicians. Standardized rate-control efficacy criteria developed a priori included resting heart rate and 6-min walk tests and/or ambulatory electrocardiographic results.

RESULTS: Average follow-up was 3.5 ± 1.3 years. Initial treatment included a beta-adrenergic blocker (beta-blocker) alone in 24%, a calcium channel blocker alone in 17%, digoxin alone in 16%, a beta-blocker and digoxin in 14%, or a calcium channel blocker and digoxin in 14% of patients. Overall rate control was achieved in 70% of patients given beta-blockers as the first drug (with or without digoxin), 54% with calcium channel blockers (with or without digoxin), and 58% with digoxin alone. Adequate overall rate control was achieved in 58% of patients with the first drug or combination. Multivariate analysis revealed an association between first drug class and several clinical variables. There were more changes to beta-blockers than to the other two-drug classes (p < 0.0001).

CONCLUSIONS: Rate control in AF is possible in the majority of patients with AF. Beta-blockers were the most effective drugs. To achieve the goal of adequate rate control in all patients, frequent medication changes and drug combinations were needed.

Abbreviations and Acronyms   AF = atrial fibrillation   AFFIRM = Atrial Fibrillation Follow-up Investigation of Rhythm Management study   AV = atrioventricular   HF = heart failure   HR = heart rate   MI = myocardial infarction   SR = sinus rhythm

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