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Original Article

Rate Control versus Rhythm Control for Atrial Fibrillation after Cardiac Surgery

A. Marc Gillinov, M.D., Emilia Bagiella, Ph.D., Alan J. Moskowitz, M.D., Jesse M. Raiten, M.D., Mark A. Groh, M.D., Michael E. Bowdish, M.D., Gorav Ailawadi, M.D., Katherine A. Kirkwood, M.S., Louis P. Perrault, M.D., Michael K. Parides, Ph.D., Robert L. Smith II, M.D., John A. Kern, M.D., Gladys Dussault, R.N., Amy E. Hackmann, M.D., Neal O. Jeffries, Ph.D., Marissa A. Miller, D.V.M., Wendy C. Taddei-Peters, Ph.D., Eric A. Rose, M.D., Richard D. Weisel, M.D., Deborah L. Williams, B.S.N., M.P.H., Ralph F. Mangusan, R.N., Michael Argenziano, M.D., Ellen G. Moquete, R.N., Karen L. O’Sullivan, M.P.H., Michel Pellerin, M.D., Kinjal J. Shah, P.A., James S. Gammie, M.D., Mary Lou Mayer, B.S.N., Pierre Voisine, M.D., Annetine C. Gelijns, Ph.D., Patrick T. O’Gara, M.D., and Michael J. Mack, M.D., for the CTSN

N Engl J Med | April 4, 2016 |DOI: 10.1056/NEJMoa1602002

Atrial fibrillation after cardiac surgery is associated with increased rates of death,
complications, and hospitalizations. In patients with postoperative atrial fibrillation
who are in stable condition, the best initial treatment strategy — heart-rate
control or rhythm control — remains controversial.

Patients with new-onset postoperative atrial fibrillation were randomly assigned to
undergo either rate control or rhythm control. The primary end point was the
total number of days of hospitalization within 60 days after randomization, as
assessed by the Wilcoxon rank-sum test.

Postoperative atrial fibrillation occurred in 695 of the 2109 patients (33.0%) who
were enrolled preoperatively; of these patients, 523 underwent randomization. The
total numbers of hospital days in the rate-control group and the rhythm-control
group were similar (median, 5.1 days and 5.0 days, respectively; P=0.76). There
were no significant between-group differences in the rates of death (P=0.64) or
overall serious adverse events (24.8 per 100 patient-months in the rate-control
group and 26.4 per 100 patient-months in the rhythm-control group, P=0.61),
including thromboembolic and bleeding events. About 25% of the patients in each
group deviated from the assigned therapy, mainly because of drug ineffectiveness
(in the rate-control group) or amiodarone side effects or adverse drug reactions (in
the rhythm-control group). At 60 days, 93.8% of the patients in the rate-control
group and 97.9% of those in the rhythm-control group had had a stable heart
rhythm without atrial fibrillation for the previous 30 days (P=0.02), and 84.2%
and 86.9%, respectively, had been free from atrial fibrillation from discharge to
60 days (P=0.41).

Strategies for rate control and rhythm control to treat postoperative atrial fibrillation
were associated with equal numbers of days of hospitalization, similar complication
rates, and similarly low rates of persistent atrial fibrillation 60 days after
onset. Neither treatment strategy showed a net clinical advantage over the other.
(Funded by the National Institutes of Health and the Canadian Institutes of Health
Research; ClinicalTrials.gov number, NCT02132767.)

 Originally Appeared in The New England Journal of Medicine on April 4, 2016.

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