Objective To investigate whether the results of a rhythm control strategy differ according to the duration between diagnosis of atrial fibrillation and treatment initiation. Design Longitudinal observational cohort study. Setting Population based cohort from the Korean National Health Insurance Service database. Participants 22 635 adults with atrial fibrillation and cardiovascular conditions, newly treated with rhythm control (antiarrhythmic drugs or ablation) or rate control strategies between 28 July 2011 and 31 December 2015. Main outcome measure A composite outcome of death from cardiovascular causes, ischaemic stroke, admission to hospital for heart failure, or acute myocardial infarction. Results Of the study population, 12 200 (53.9%) were male, the median age was 70, and the median follow-up duration was 2.1 years. Among patients with early treatment for atrial fibrillation (initiated within one year since diagnosis), compared with rate control, rhythm control was associated with a lower risk of the primary composite outcome (weighted incidence rate per 100 person years 7.42 in rhythm control v 9.25 in rate control; hazard ratio 0.81, 95% confidence interval 0.71 to 0.93; P=0.002). No difference in the risk of the primary composite outcome was found between rhythm and rate control (weighted incidence rate per 100 person years 8.67 in rhythm control v 8.99 in rate control; 0.97, 0.78 to 1.20; P=0.76) in patients with late treatment for atrial fibrillation (initiated after one year since diagnosis). No significant differences in safety outcomes were found between the rhythm and rate control strategies across different treatment timings. Earlier initiation of treatment was linearly associated with more favourable cardiovascular outcomes for rhythm control compared with rate control. Conclusions Early initiation of rhythm control treatment was associated with a lower risk of adverse cardiovascular outcomes than rate control treatment in patients with recently diagnosed atrial fibrillation. This association was not found in patients who had had atrial fibrillation for more than one year.
Bibliographical noteFunding Information:
We thank the National Health Insurance Service of Korea for providing invaluable data. Contributors: DK and P-SY contributed equally to this work. BJ and GYHL are joint senior authors and contributed to the conception and design of the work and critical revision of the manuscript. DK contributed to the conception and design of the work, interpretation of data, and drafting of the manuscript. P-SY and EJ contributed to the acquisition and analysis of data. SCY, J-HS, HTY, T-HK, H-NP, and M-HL contributed to the conception and design of the work and revision of the manuscript. All authors approved the final version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. Funding: This study was supported by grants from the Korean Healthcare Technology research and development project funded by the Korean Ministry of Health and Welfare (HI15C1200, HC19C0130), and by a CMB-Yuhan research grant from the Yonsei University College of Medicine (6-2019-0124). The funders of this study had no role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the manuscript for publication. Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; GYHL has served as a consultant for Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Novartis, Verseon, and Daiichi-Sankyo and as a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, and Daiichi-Sankyo. No fees have been received directly or personally. BJ has served as a speaker for Bayer, BMS/Pfizer, Medtronic, and Daiichi-Sankyo and received research funds from Medtronic and Abbott. No fees have been received directly or personally. The remaining authors have no other relationships or activities that could appear to have influenced the submitted work. Ethical approval: This study was approved by the institutional review board of Yonsei University Health System (No 4-2016-0179), which waived the requirement for informed consent as only deidentified data were used in this study. Data sharing: Data sharing is not possible because of legislation from the Korean government. Additional data are available through approval and oversight by the Korean National Health Insurance Service.
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