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J Am Coll Cardiol, 2008; 52:1239-1246, doi:10.1016/j.jacc.2008.06.043
© 2008 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: CARDIAC RESYNCHRONIZATION THERAPY

Cardiac Resynchronization in Patients With Atrial Fibrillation

A Meta-Analysis of Prospective Cohort Studies

Gaurav A. Upadhyay, MD*, Niteesh K. Choudhry, MD, PhD{dagger}, Angelo Auricchio, MD, PhD{ddagger}, Jeremy Ruskin, MD* and Jagmeet P. Singh, MD, PhD*,*

* Department of Medicine and the Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
{dagger} Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
{ddagger} Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland

Manuscript received March 3, 2008; revised manuscript received May 22, 2008, accepted June 7, 2008.

* Reprint requests and correspondence: Dr. Jagmeet P. Singh, Cardiac Arrhythmia Service, Cardiology Division, Gray Building 109, 55 Fruit Street, Boston, Massachusetts 02114 (Email: jsingh{at}partners.org).

Objectives: This study is a meta-analysis of prospective cohort studies comparing the impact of cardiac resynchronization therapy (CRT) for patients in atrial fibrillation (AF) and sinus rhythm (SR).

Background: Although close to one-third of advanced heart failure patients exhibit AF, the impact of CRT in this group remains unclear.

Methods: Prospective cohort studies comparing patients in normal SR and chronic AF treated with CRT were included. All studies reported death, New York Heart Association functional class, ejection fraction, 6-min walk test, and the Minnesota score or its equivalent as outcomes. Data sources included Ovid MEDLINE In-Process & Other Non-Indexed Citations, the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews of Effects, and the American College of Physicians Journal Club.

Results: Of 2,487 reports identified, 5 studies following a total of 1,164 patients were included. Both AF and SR patients benefited significantly from CRT. Mortality was not significantly different at 1 year (relative risk ratio: 1.57, 95% confidence interval [CI]: 0.87 to 2.81). The New York Heart Association functional class improved similarly for both groups (–0.90 for SR patients, –0.84 for AF patients). SR patients showed greater relative improvement in the 6-min walk test (11.6 m greater, 95% CI: 10.4 to 12.8 m) and the Minnesota score (3.9 points less, 95% CI: 3.4 to 4.5 points) than AF patients. AF patients, however, achieved a small but statistically significant greater change in ejection fraction (0.39% greater change in ejection fraction, 95% CI: 0.22% to 0.55%).

Conclusions: Patients in AF show significant improvement after CRT, with similar or improved ejection fraction as SR patients, but smaller benefits in regard to functional outcomes.

Key Words: atrial fibrillation • biventricular pacemaker • cardiac resynchronization • congestive heart failure treatment

Abbreviations and Acronyms
  6MWD = 6-min walking distance
  AF = atrial fibrillation
  AVJ = atrioventricular junction
  CI = confidence interval
  CRT = cardiac resynchronization therapy
  LVEF = left ventricular ejection fraction
  MLWHF = Minnesota Living With Heart Failure
  NYHA = New York Heart Association
  QOL = quality of life


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