Critical Appraisal Lenient versus Strict Rate Control in Patients with Atrial Fibrillation(NEJM April 15, 2010 )

1. Lenient versus Strict Rate Control in Patients with Atrial Fibrillation (NEJM April 15, 2010 ) Piti Niyomsirivanich ,MD.

4. RACE trial RA te C ontrol versus E lectrical cardioversion for persistent atrial fibrillation study group

5. A Comparison of Rate Control and Rhythm Control in Patients with Recurrent Persistent Atrial Fibrillation NEJM Volume 347:1834-1840 December 5, 2002

6. AFFIRM Trial A trial F ibrillation F ollow-up I nvestigation of R hythm M anagement

7. Cumulative Mortality from Any Cause in the Rhythm-Control Group and the Rate-Control Group. A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation NEJM Volume 347:1825-1833 December 5, 2002

9. Criteria for rate control vary with patient age but usually involve achieving ventricular rates between 60 and 80 beats per minute at rest and between 90 and 115 beats per minute during moderate exercise.

14. Methods 33 Centers in the Netherlands Jan 2005 - June 2007 Eligibility criteria AF up to 12 months Age <80 Resting rate > 80 Current use of anticoagulant therapy or aspirin

21. 614 patients enrolled 33 Centers in the Netherlands Jan 2005 - June 2007 Lenient control 311 Strict control 303 Randomization

25. Randomization and Follow-up of the Study Patients.

27. Rate Control Targets and Drug Therapy at the End of the Dose-Adjustment Phase

28. Primary outcome Hazard ratio 0.84 95%CI 0.58 to 1.21 Lenient Control is NONINFERIOR to Strict Control

30. Secondary Outcome Lenient Control Strict Control Death from any cause 17 (5.6%) 18 (6.6%) Death from CVS 8 7 Symptom associate with AF Dyspnea 30% 29.6% Fatigue 24.4% 22.6% palpitation 10.6% 9.5%

31. Secondary Outcome NYHA classification Lenient Control Strict Control Class I 70.0% 70.4% Class II 23.3% 23.4% Class III 6.7% 6.2% Class IV 0 % 0 %

32. Subgroup Analysis (CHADS2 score =2 or more) Subgroup Analysis (CHADS2 score <2) Lenient Control Strict Control Primary outcome 17/133 25/108 Lenient Control Strict Control Primary outcome 21/178 18/195

33. Criticized Paper

41. Thank you