Rate versus rhythm control and outcomes in patients with atrial fibrillation and chronic kidney disease: Data from the GUSTO-III Trial

Abstract

Background: Atrial fi brillation (AF) and chronic kidney disease (CKD) have both been
shown to portend worse outcomes after acute myocardial infarction (MI); however, the benefi t
of a rhythm control strategy in patients with CKD post-MI is unclear.

Methods: We prospectively studied 985 patients with new-onset AF post-MI in the
GUSTO-III trial, of whom 413 (42%) had CKD (creatinine clearance < 60 mL/min).
A rhythm control strategy, defi ned as the use of an antiarrhythmic medication and/or
electrical cardioversion, was used in 346 (35%) of patients.

Results: A rhythm control strategy was used in 34% of patients with CKD and 36% of patients
with no CKD. At hospital discharge, sinus rhythm was present in 487 (76%) of patients treated
with a rate control strategy, vs. 276 (80%) in those treated with rhythm control (p = 0.20). CKD
was associated with a lower odds of sinus rhythm at discharge (unadjusted OR 0.56, 95% CI
0.38–0.84, p < 0.001). However, in multivariable analyses, treatment with a rhythm control
strategy was not associated with discharge rhythm (HR 1.068, 95% CI 0.69–1.66, p = 0.77),
30-day mortality (HR 0.78, 95% CI 0.54–1.12, p = 0.18) or mortality from day 30 to 1 year
(HR 1.00, 95% CI 0.59–1.69, p = 0.99). CKD status did not signifi cantly impact the relationship
between rhythm control and outcomes.

Conclusions: Treatment with a rhythm or rate control strategy does not signifi cantly impact
short-term or long-term mortality in patients with post-MI AF, regardless of kidney disease status.
Future studies to investigate the optimal management of AF in CKD patients are needed.