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J Am Coll Cardiol, 2004; 43:1201-1208, doi:10.1016/j.jacc.2003.11.032
© 2004 by the American College of Cardiology Foundation
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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{dagger}, Alberta L. Warner, MD, FACC{ddagger}, 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{dagger}{dagger}, H. Leon Greene, MD, FACC{ddagger}{ddagger} AFFIRM Investigators§§

* University of Iowa, Iowa City, Iowa, USA
{dagger} Yale University School of Medicine, New Haven, Connecticut, USA
{ddagger} 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
{dagger}{dagger} University of California at Irvine, Irvine, California, USA
{ddagger}{ddagger} 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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