Impact of treatment crossovers on clinical outcomes in the rate and rhythm control strategies for atrial fibrillation: Insights from the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trial

Abhishek Maan, Zheng Zhang, Ziling Qin, Yanbing Wang, Samuel Dudley, Kaustubh Dabhadakar, Marwan Refaat, Moussa Mansour, Jeremy N. Ruskin, E. Kevin Heist

Research output: Contribution to journalArticlepeer-review

Abstract

We investigated the rates and reasons for crossover to alternative treatment strategies and its impact on mortality in patients who were enrolled in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. Over a mean follow-up period of 3.5 years, 842 patients underwent crossover to the alternative treatment arms in AFFIRM. The rate of crossover from rhythm to rate control (594/2,033, 29.2%) was more frequent than the rate of crossover from rate to rhythm control (248/2,027, 12.2%, P < 0.0001). The leading reasons for crossover from rhythm to rate control were failure to achieve or maintain sinus rhythm (272/594, 45.8%) and intolerable adverse effects (122/594, 20.5%). In comparison, the major reasons for crossover from rate to rhythm control were failure to control atrial fibrillation symptoms (159/248, 64.1%) and intolerable adverse effects (9/248, 3.6%). This difference in crossover pattern was statistically significant (P < 0.0001). There was a significantly decreased risk of all-cause mortality (adjusted HR: 0.61, 95% CI: 0.48–0.78, P < 0.0001) and cardiac mortality (adjusted hazard ratio [HR]: 0.61, 95% confidence interval [CI]: 0.43–0.88, P = 0.008) in the subgroup of patients who crossed over from rhythm to rate control as compared to those who continued in rhythm control. There was a nonsignificant trend toward decreased all-cause (adjusted HR: 0.76, 95% CI: 0.53–1.10, P = 0.14) and cardiac mortality (adjusted HR: 0.70, 95% CI: 0.42–1.18, P = 0.18) in patients who crossed over from rate to rhythm control as compared to those who continued rate control.

Original languageEnglish (US)
Pages (from-to)770-778
Number of pages9
JournalPACE - Pacing and Clinical Electrophysiology
Volume40
Issue number7
DOIs
StatePublished - Jul 2017
Externally publishedYes

Keywords

  • AFFIRM
  • atrial fibrillation
  • crossover
  • rate and rhythm control strategies

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