Dataset Information

Treatment timing and the effects of rhythm control strategy in patients with atrial fibrillation: nationwide cohort study.

ABSTRACT:

Objective

To investigate whether the results of a rhythm control strategy differ according to the duration between diagnosis of atrial fibrillation and treatment initiation.

Design

Longitudinal observational cohort study.

Setting

Population based cohort from the Korean National Health Insurance Service database.

Participants

22 635 adults with atrial fibrillation and cardiovascular conditions, newly treated with rhythm control (antiarrhythmic drugs or ablation) or rate control strategies between 28 July 2011 and 31 December 2015.

Main outcome measure

A composite outcome of death from cardiovascular causes, ischaemic stroke, admission to hospital for heart failure, or acute myocardial infarction.

Results

Of the study population, 12 200 (53.9%) were male, the median age was 70, and the median follow-up duration was 2.1 years. Among patients with early treatment for atrial fibrillation (initiated within one year since diagnosis), compared with rate control, rhythm control was associated with a lower risk of the primary composite outcome (weighted incidence rate per 100 person years 7.42 in rhythm control v 9.25 in rate control; hazard ratio 0.81, 95% confidence interval 0.71 to 0.93; P=0.002). No difference in the risk of the primary composite outcome was found between rhythm and rate control (weighted incidence rate per 100 person years 8.67 in rhythm control v 8.99 in rate control; 0.97, 0.78 to 1.20; P=0.76) in patients with late treatment for atrial fibrillation (initiated after one year since diagnosis). No significant differences in safety outcomes were found between the rhythm and rate control strategies across different treatment timings. Earlier initiation of treatment was linearly associated with more favourable cardiovascular outcomes for rhythm control compared with rate control.

Conclusions

Early initiation of rhythm control treatment was associated with a lower risk of adverse cardiovascular outcomes than rate control treatment in patients with recently diagnosed atrial fibrillation. This association was not found in patients who had had atrial fibrillation for more than one year.

SUBMITTER: Kim D

PROVIDER: S-EPMC8111568 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundAtrial 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.MethodsPatients 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.ResultsPostoperative 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).ConclusionsStrategies 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.).

Project description:BackgroundThe identification of an appropriate rhythm management strategy for patients diagnosed with atrial fibrillation (AF) remains a major challenge for providers. Although clinical trials have identified subgroups of patients in whom a rate- or rhythm-control strategy might be indicated to improve outcomes, the wide range of presentations and risk factors among patients presenting with AF makes such approaches challenging. The strength of electronic health records is the ability to build in logic to guide management decisions, such that the system can automatically identify patients in whom a rhythm-control strategy is more likely and can promote efficient referrals to specialists. However, like any clinical decision support tool, there is a balance between interpretability and accurate prediction.ObjectiveThis study aims to create an electronic health record-based prediction tool to guide patient referral to specialists for rhythm-control management by comparing different machine learning algorithms.MethodsWe compared machine learning models of increasing complexity and used up to 50,845 variables to predict the rhythm-control strategy in 42,022 patients within the University of Colorado Health system at the time of AF diagnosis. Models were evaluated on the basis of their classification accuracy, defined by the F1 score and other metrics, and interpretability, captured by inspection of the relative importance of each predictor.ResultsWe found that age was by far the strongest single predictor of a rhythm-control strategy but that greater accuracy could be achieved with more complex models incorporating neural networks and more predictors for each participant. We determined that the impact of better prediction models was notable primarily in the rate of inappropriate referrals for rhythm-control, in which more complex models provided an average of 20% fewer inappropriate referrals than simpler, more interpretable models.ConclusionsWe conclude that any health care system seeking to incorporate algorithms to guide rhythm management for patients with AF will need to address this trade-off between prediction accuracy and model interpretability.