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Upstream rhythm control superior to conventional therapy for atrial fibrillation

Dr. Joseph Delano Fule Robles
30 Aug 2017
Prof Isabelle Van Gelder

Risk factor driven upstream therapy, including treatment of risk factors and lifestyle modification, is effective and feasible to improve maintenance of sinus rhythm in patients with early persistent atrial fibrillation (AF), according to late-breaking results from the RACE 3 trial presented at the European Society of Cardiology Congress 2017 (ESC 2017) held in Barcelona, Spain.

In this international, prospective, randomized, open-label trial where 250 patients with symptomatic, early persistent AF and early mild-to-moderate heart failure were included, sinus rhythm was attained at 1 year in a significantly higher proportion of patients who received risk factor driven upstream therapy vs conventional treatment (75 vs 63 percent; odds ratio [OR], 1.765; p=0.021).

The multicentre study (n=245), conducted between 2009 and 2015, included predominantly male patients (80 percent, mean age 65 years). The results also showed greater decreases in systolic and diastolic blood pressure, N-terminal pro b-type natriuretic peptide (NT-proBNP) and LDL-cholesterol levels in the risk factor-driven upstream therapy group vs conventional treatment group at 1-year follow-up (p<0.05).

“Risk factor-driven upstream therapy refers to interventions that aim to modify the atrial substrate with favourable effects on risk factors and diseases underlying AF. In the study, the upstream therapy group received cardiac rehabilitation including physical activity, dietary restrictions and regular counselling, mineralocorticoid receptor antagonists, statins and angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers,” said investigator Professor Isabelle Van Gelder of the University of Groningen, The Netherlands.

The primary endpoint (ie, the presence of sinus rhythm after 1 year of follow-up) was assessed with continuous 7-day Holter monitoring during the last week of the study.

“Note that in the conventional treatment group, 63 percent of patients achieved sinus rhythm at 1 year. In this group, 43 percent of patients received anti-arrhythmic drugs and 2 percent underwent atrial ablation. The benefit [of risk factor-driven upstream therapy] would probably be even greater if this group was not treated,” discussant Professor Joseph Brugada of the Hospital Clinic, University of Barcelona, Spain, commented.

“Weight and body mass index [BMI], the presence of alcohol abuse, and the intensity of exercise are some of the other factors that may affect the incidence of AF. If we address all of these factors and include them in further studies, we would be able to administer more effective preventive therapy and reduce the number of AF patients and the overall burden of this disease in our society,” Brugada added.

“The effect [of upstream therapy] instead of atrial remodelling was favourable and may contribute to the shift of focus on risk factor modification to improve AF outcomes,” Van Gelder concluded.

Sinus rhythm maintenance is cumbersome due to atrial remodelling, caused by risk factors and diseases underlying AF and AF itself. [Circ Arrhythm Electrophysiol 2008;1:62-73]

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