Siddiqi Rabbia, Fares Anas, Mahmoud Mona, Asghar Kanwal, Assaly Ragheb, Eltahawy Ehab, Grubb Blair, Moukarbel George V
Division of Internal Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH, 43614, USA.
Division of Cardiovascular Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH, 43614, USA.
Indian Pacing Electrophysiol J. 2024 Nov-Dec;24(6):321-329. doi: 10.1016/j.ipej.2024.09.004. Epub 2024 Sep 11.
Patients with concurrent heart failure (HF) and atrial fibrillation (AF) have poor outcomes. Randomized clinical trials comparing rhythm control approaches to rate control of AF have yielded conflicting results and there is a paucity of updated and comprehensive evidence summaries to inform best practice in HF patients. We therefore conducted a systematic review and meta-analysis to compare outcomes with rhythm versus rate control of AF in various subgroups of HF patients. In HF patients overall, we found high certainty evidence that rhythm control decreased all-cause and cardiovascular mortality (hazard ratio [HR, 95 % confidence interval] 0.64 [0.43-0.94]) and HR 0.50 [0.34-0.74] respectively). Rhythm control was associated with decreased HF hospitalization (risk ratio [RR] 0.79 [0.63-0.99], moderate certainty), but did not significantly decrease thromboembolic events (RR 0.67 [0.32-1.39], low certainty). The mean difference in left ventricular ejection fraction [LVEF] from baseline to last follow-up was greater in rhythm control group by 6.01 % [2.73-9.28 %] compared with rate control. Subgroup analyses by age, HF etiology (ischemic or non-ischemic), LVEF, presence of diabetes and hypertension did not reveal any significant differences in treatment effect. The survival and hospitalization reduction benefit of rhythm control of AF in HF patients likely reflects the success of catheter ablation especially in HF with reduced ejection fraction. These data are important to guide shared decision-making when managing AF in HF patients.
合并心力衰竭（HF）和心房颤动（AF）的患者预后较差。比较AF节律控制与心率控制方法的随机临床试验结果相互矛盾，且缺乏最新的综合证据总结来指导HF患者的最佳治疗实践。因此，我们进行了一项系统评价和荟萃分析，以比较HF患者不同亚组中AF节律控制与心率控制的疗效。总体而言，在HF患者中，我们发现有高确定性证据表明节律控制可降低全因死亡率和心血管死亡率（风险比[HR，95%置信区间]分别为0.64[0.43 - 0.94]和0.50[0.34 - 0.74]）。节律控制与HF住院率降低相关（风险比[RR]为0.79[0.63 - 0.99]，中等确定性），但未显著降低血栓栓塞事件（RR为0.67[0.32 - 1.39]，低确定性）。与心率控制组相比，节律控制组从基线到末次随访时左心室射血分数[LVEF]的平均差异高6.01%[2.73 - 9.28%]。按年龄、HF病因（缺血性或非缺血性）、LVEF、糖尿病和高血压的存在情况进行亚组分析，未发现治疗效果有任何显著差异。HF患者中AF节律控制对生存和住院率降低的益处可能反映了导管消融的成功，尤其是在射血分数降低的HF患者中。这些数据对于指导HF患者AF管理中的共同决策很重要。
