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Since transition disease has become a reality with the aging of the population, non-valvular AF appears as a new challenge in the scope of cardiology.
There are two strategies in the treatment of atrial fibrillation. One of them is cardioversion and maintenance of sinus rhythm with antiarrhythmic drugs; the other one is respect of AF and treatment with rate control drugs.
The two strategies were widely compared in the Affirm Study Without superiority of any of them. However, with a focus on the population studied in Affirm, we notice that it concerned old population at high risk of Stroke.
The aim of our study is then to compare the two strategies from another angle by targeting a population of younger and more active patients with AF.
We randomly assigned, in a prospective open-label study, 266 eligible patients with non- valvular AF, average age 52,41±9,6 years, 174 men (65,4 %,sex ratio 1,89), to undergo a rhythm control (R=131 patients) or a rate Control (F=131 pts) strategy.
The average follow -up (FU) was 27,18 months with 4 patients lost of view.
15 pts (8 and 7) were concerned by cross over from one strategy to the other.
240 pts (90%) pts were symptomatic. AF was paroxystic in 97 pts (36%), persistent in 61pts (23%) and permanent in 108pts (41%). 203 pts had comorbidities particularly hypertension in 142 (53%) and diabetes in 34 (13%). Isolated AF was present in 63pts (24%).219 pts (82%) were at low thromboembolic risk with a CHADS2 score ≤1. The hemodynamic status was favorable with an average LVEF of 64%.
There were fewer events in the R arm than in the F one, appearing late during FU but the difference wasn't statistically significant. There was no significant difference in survival without heart failure or ischemic stroke, respectively 83.8% [CI: 68.5- 100] and 56.6% [36.4-88], p=0.43.
These results can be explained by the young age of the population with a low risk in which the events are rare and late in a chronic disease that requires treatment and long term follow up. For more than 2 years FU, superiority of rhythm control over rate control wasn't demonstrated despite the patients’ profile that seemed to be favorable. However, given the shape of the survival curves, we can anticipate a superiority of rhythm control in the long term.