AFFIRM
A comparison of rate control and rhythm control in patients with atrial fibrillation
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Overview
In older high-risk AF patients, rhythm control did not improve survival compared with rate control.
Clinical takeaway
AFFIRM made rate control an acceptable default strategy for many stable AF patients, especially older patients with stroke risk factors, while preserving rhythm control for symptoms or selected patients.
Key result
Five-year mortality was 23.8% with rhythm control vs 21.3% with rate control; HR 1.15, p=0.08.
Practice impact
Rate control plus anticoagulation became a standard approach for stable AF when symptoms are controlled.
Evidence
Study design
Randomized, multicenter strategy trial.
Enrollment
4,060
Follow-up
Mortality reported at 5 years.
Geography
United States, Canada
Clinical question
Is rhythm control superior to rate control for mortality in atrial fibrillation?
Population
- Patients with atrial fibrillation at high risk for stroke or death (age >=65 or other stroke risk factors).
Intervention
Rhythm-control strategy using antiarrhythmic drugs and cardioversion as needed.
Comparator
Rate-control strategy with anticoagulation as indicated.
Primary outcome
All-cause mortality.
Rhythm control did not improve survival compared with rate control.
Hazard ratio / 1.15 / CI 95% CI 0.99-1.34 / p=0.08
Key results
- Five-year mortality was 23.8% with rhythm control vs 21.3% with rate control; HR 1.15; 95% CI 0.99-1.34; p=0.08.
- Hospitalizations and adverse drug effects were more common with rhythm-control therapy.
- Most strokes occurred after warfarin had been stopped or when the INR was subtherapeutic.
Harms
- Hospitalizations and adverse drug effects were more common with rhythm-control therapy.
Clinical Use
When to cite
- When explaining that rate control is an acceptable initial strategy for many stable patients with atrial fibrillation, with anticoagulation based on stroke risk rather than apparent rhythm success.
Practice impact
- Rate control plus anticoagulation became a standard approach for stable AF when symptoms are controlled.
Applicability
- Most applicable to patients with atrial fibrillation at high risk for stroke or death.
Limitations
- Older antiarrhythmic-era trial (amiodarone/sotalol), before widespread catheter ablation.
- Does not exclude benefit of early rhythm control, ablation, or rhythm control for symptoms in selected patients.
Common misinterpretations
- Anticoagulation should continue based on stroke risk regardless of apparent rhythm-control success; most strokes occurred after warfarin was stopped or when subtherapeutic.
- AFFIRM does not apply to early rhythm control or ablation; EAST-AFNET 4 later showed benefit from early rhythm control in recently diagnosed AF.
Related evidence
Citation
Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347(23):1825-1833. doi:10.1056/NEJMoa021328
Management of atrial fibrillation with the rhythm-control strategy offers no survival advantage over the rate-control strategy, and there are potential advantages, such as a lower risk of adverse drug effects, with the rate-control strategy.
- PMID
- 12466506