Early rhythm control in patients with acute decompensated heart failure

Abstract Background Early rhythm control improves outcomes in patients with atrial fibrillation (AF) and heart failure. The role of rhythm control in acute heart failure (AHF) remains uncertain. Purpose This study aimed to assess patient characteristics, independent predictors of decision for early rhythm control and its success, and associations between treatment strategies and outcomes in patients with AHF. Methods This analysis used data from a prospective cohort study (CYCLE) enrolling consecutive patients with new or worsening heart failure. All patients were enrolled from 2019 and followed until July 2024. Rhythm control therapy was defined as cardioversion, use of antiarrhythmic drugs (amiodarone, dronedarone, flecainide, or propafenone) or AF ablation. Rhythm control success was defined by a sinus rhythm in the electrocardiogram at discharge. Multivariable logistic regression was used to identify independent predictors for early rhythm control initiation and its success during the AHF episode. Cox regression analysis was performed to assess associations between treatment strategies and all-cause mortality. Results Among 370 patients hospitalised due to AHF, 187 (50.5%) had AF. AHF patients with AF were older (median 76 years; 69.4% men) than patients with AHF without AF (median 70 years; 69.0% men). Early rhythm control was used in 41 (21.9%) patients, 146 (78.1%) received usual care. Independent predictors of early rhythm control included higher baseline heart rate (odds ratio OR per standard deviation SD: 1.78 1.28-2.54) and new-onset heart failure (OR per SD: 1.59 1.16-2.19). Lower likelihood of choosing early rhythm control was observed in those with coronary artery disease (CAD) (OR per SD: 0.59 0.41-0.84), ischemic cardiomyopathy (OR per SD: 0.59 0.39-0.85), anaemia (OR per SD: 0.58 0.40-0.83), beta-blocker use (OR per SD: 0.73 0.54-1.00), and statin use (OR per SD: 0.70 0.49-0.99). Successful early rhythm control was independently associated with higher baseline heart rate (OR per SD: 1.79 1.22-2.66), new-onset heart failure (OR per SD: 1.54 1.08-2.19), and with amiodarone loading (OR per SD: 4.41 2.91-7.38). Contrarily, a lower likelihood of successful early rhythm control was seen in patients with CAD (OR per SD: 0.47 0.30-0.74), ischemic cardiomyopathy (OR per SD: 0.55 0.34-0.89), and beta-blocker use (OR per SD: 0.69 0.49-1.00). Over a median follow-up of 2.67 years (95% CI 2.09-3.85), early rhythm control was associated with a lower all-cause mortality (hazard ratio HR: 0.51 0.27-0.93; p=0.029) in patients with AF and AHF (Figure 1A). Similarly, over a median follow-up of 2.57 years (95% CI 1.73-4.43), successful early rhythm control was associated with lower all-cause mortality (HR: 0.25 0.09-0.69; p=0.0073) (Figure 1B). Conclusion These hypothesis-generating results support the evaluation of early rhythm control for outcome reduction in patients with AHF and AF.