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BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.a436 (Published 26 June 2008) Cite this as: BMJ 2008;336:1462

Control rate, not rhythm, in patients with atrial fibrillation and heart failure

Atrial fibrillation is common and associated with an increased risk of death. Attempts to restore sinus rhythm in patients with atrial fibrillation have so far failed to improve survival, however. The latest trial focused on patients with both atrial fibrillation and heart failure, to see if rhythm control might prove useful for this vulnerable subgroup. It didn’t. Patients treated with cardioversion and antiarrhythmic drugs (four fifths received amiodarone) survived no longer than those given drugs to control just heart rate, not rhythm. About a third of the patients in each group died during an average follow-up of three years (217/682 (32%) of the rhythm control group, and 228/694 (33%) of the rate control group, P=0.68). About a quarter died from cardiovascular causes (182/682 (27%) v 175/694 (25%), hazard ratio 1.06, 95% CI 0.86 to 1.3).

Perhaps the treatment strategy used to control rhythm simply wasn’t good enough, say the authors. A quarter of the patients in this group still had atrial fibrillation at the end of the trial. Or perhaps amiodarone’s well known toxicity wiped out any survival gains from rhythm control. A linked editorial (pp 2725-6) agrees that until better treatments are available doctors should stick to controlling rate in patients with atrial fibrillation and a poorly functioning left ventricle.

Dronedarone is unsafe for people with heart failure

Dronedarone is a new class III antiarrhythmic drug under development by Sanofi-Aventis for the treatment of atrial fibrillation. It was designed to be less toxic than amiodarone, but the manufacturers recently published data showing that the new drug could be dangerous for some people with heart failure. Back in 2003, they terminated a placebo controlled trial halfway through recruitment when it became clear that dronedarone was associated with a significant excess of deaths. All the participants had severe heart failure and a …

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