Comparative Effectiveness of Rhythm Control vs Rate Control Drug Treatment Effect on Mortality in Patients With Atrial Fibrillation

Figure 1. Derivation of the study population. For each patient, we identified first his or her first hospitalization for atrial fibrillation (AF) recorded in the Med-Echo database from January 1999 to March 2007. There were 3 main categories for exclusions: patients whose billings in the year before the index AF hospitalization indicated that the individual could have had prevalent AF, patients whose AF was believed to be transitory because it was induced by a reversible trigger, and patients for whom the validity of the AF diagnosis was questionable.

Figure 2. Time trends in prescription patterns before and after the publication of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial results.¹⁴ Overall trends (A) and differences in the trends between cardiovascular specialists and general practitioners (GPs) (B).The time-trend analysis of prescription patterns shows a decrease in the use of rhythm control drugs after the publication of AFFIRM results. The proportion of patients with atrial fibrillation (AF) who initiated treatment with rhythm control drugs increased by about 2% per trimester (RR, 1.02; 95% CI, 1.01-1.03) in the years before the AFFIRM trial (1999-2002), but this trend disappeared after the presentation of AFFIRM results in March 2002 (RR, 0.98; 95% CI, 0.97-0.98 for years 2002 to 2007). The change in the temporal trend was statistically significant (interaction P < .001) (A) and was similar for cardiovascular specialists and GPs (B).

Figure 3. Weighted survival of patients with atrial fibrillation (AF) on rhythm vs rate control treatment. The weighted survival curves were weighted by inverse probabilities of treatment that are equivalent to the standardization of the survival curves to the whole study population.²⁰ The deaths in the footnote are counted in the preceding 1-year interval. The number of patients at risk in the footnote are counted at the end of each 1-year interval.

Figure 4. Effect of rhythm vs rate control therapy on mortality. Point estimates and 95% CIs can be reported at selected time points during the follow-up. The adjusted hazard ratio (HR) at a corresponding point in time quantifies the relative risks of immediate death, for rhythm vs rate control drugs, among patients who were followed until that time (ie, had not died and were not censored until that time). AF indicates atrial fibrillation.