CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Robby Nieuwlaat, PhD*,
Luc W. Eurlings, MD and
Harry J.G.M. Crijns, MD, PhD
* Department of Cardiology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands (Email: nieuwlaatrobby{at}live.com.au).
We thank Dr. Smit and colleagues and Drs. Fauchier and Gorin for their interest in our paper (1) regarding the characteristics, management, and prognosis of patients with the combination of atrial fibrillation (AF) and heart failure (HF) in the Euro Heart Survey.
First, we would like to clarify that the variable "major bleeding" in the multivariable analyses concerns a history of major bleeding at baseline, rather than major bleeding during study follow-up. We want to congratulate Fauchier et al. (2) on their interesting study showing improved survival of patients with AF and HF who receive a beta-blocker. However, we did not find a benefit of beta-blockers in our prospective survey, which was also the case in subanalyses of the CIBIS II (The Cardiac Insufficiency Bisoprolol Study II) (3) and MERIT-HF (Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure) (4) trials as pointed out by Dr. Smit and colleagues. There are multiple potential reasons for these different results, among which are study setting, selection of the population, study design, and follow-up duration. Only randomized controlled trials specifically designed to test the effect of beta-blockers among these patients can clarify this issue. The same argument holds for the rate control target issue as raised by Dr. Smit and colleagues. The AF guidelines indicate that rhythm versus rate control studies usually used a rate control target of  60 to 80 beats/min and is reasonable (5). However, it is unknown whether aiming for 80 beats/min produces superior therapeutic effects compared with a lower or higher target. The RACE II (Rate Control Efficacy in Permanent Atrial Fibrillation) trial (6) will indeed shed more light on this issue for permanent AF patients.
No or inconclusive research evidence can be a reason for suboptimal implementation of therapies. Until stronger evidence is available, we will have to rely on guideline recommendations optimally weighing the evidence as extrapolated from more general trial patient groups, observational studies such as ours, and expert opinion. Inadequate guideline adherence is a multifactorial problem of which lack of firm evidence is an important, but not the only, aspect. Ever-growing research evidence will clarify management issues that are of importance, but implementing this evidence optimally in local practice is another issue (7). Understanding the causes for gaps between guidelines and practice and finding effective ways to close them is an essential next step in the continuous feedback loop between research and practice (8). We hope that our survey and the discussions by Dr. Smit and colleagues and Drs. Fauchier and Gorin will stimulate further research to improve the care and outcomes for patients with AF and HF.
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References
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1. Nieuwlaat R, Eurlings LW, Cleland JG, et al. Atrial fibrillation and heart failure in cardiology practice: reciprocal impact and combined management from the perspective of atrial fibrillation: results of the Euro Heart Survey on atrial fibrillation J Am Coll Cardiol 2009;53:1690-1698.[Abstract/Free Full Text]2. Fauchier L, Grimard C, Pierre B, et al. Comparison of beta blocker and digoxin alone and in combination for management of patients with atrial fibrillation and heart failure Am J Cardiol 2009;103:248-254.[CrossRef][Web of Science][Medline] 3. Lechat P, Hulot JS, Escolano S, et al. Heart rate and cardiac rhythm relationships with bisoprolol benefit in chronic heart failure in CIBIS II trial Circulation 2001;103:1428-1433.[Abstract/Free Full Text] 4. van Veldhuisen DJ, Aass H, El Allaf D, et al. MERIT-HF Study Group Presence and development of atrial fibrillation in chronic heart failure. Experiences from the MERIT-HF study. Eur J Heart Fail 2006;8:539-546.[Abstract/Free Full Text] 5. Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) J Am Coll Cardiol 2006;48:854-906.[Free Full Text] 6. Van Gelder IC, Van Veldhuisen DJ, Crijns HJ, et al. Rate Control Efficacy in Permanent Atrial Fibrillation: a comparison between lenient versus strict rate control in patients with and without heart failure. Background, aims, and design of RACE II. Am Heart J 2006;152:420-426.[CrossRef][Web of Science][Medline] 7. Majumdar SR, McAlister FA, Furberg CD. From knowledge to practice in chronic cardiovascular disease: a long and winding road J Am Coll Cardiol 2004;43:1738-1742.[Abstract/Free Full Text] 8. Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof 2006;26:13-24.[CrossRef][Web of Science][Medline]
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