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Journal of the American College of Cardiology

Clinical Articles, News & Views

Strict versus lenient rate control in permanent AF

In patients with permanent atrial fibrillation (AF), successful strict rate control does not improve outcome, and lenient rate control might be preferable as frontline therapy, according to a study published recently in the Journal of the American College of Cardiology.1

The RACE II (Rate Control Efficacy in Permanent Atrial Fibrillation) study showed no difference in outcome between lenient and strict rate control in patients with permanent AF. However, in the strict group not all patients achieved the pre-defined heart rate target.

The primary outcome was a composite of cardiovascular morbidity and mortality. For the current analysis outcome events were analyzed from end of the dose-adjustment phase until end of follow-up (median 2.9 years [interquartile range: 2.4 to 3.0 years]). Of 614 patients, 608 completed the dose-adjustment phase—301 in the strict (resting heart rate <80 beats/min, and during moderate exercise <110 beats/min) and 307 in the lenient group (resting heart rate <110 beats/min). In the strict group, 203 of 301 patients achieved the rate control target, and 98 failed.

Heart rate was different after the dose-adjustment phase between the successful strict (72 ± 7 beats/min), failed strict (86 ± 14 beats/min), and lenient (93 ± 8 beats/min) group (p<0.001) and remained significantly

different during follow-up. The primary outcome was reached in 27 of 203 (14.2% KM estimate) in the successful strict versus 14 of 98 (15%) in the failed strict versus 35 of 307 (12.1%) in the lenient group (p = 0.5). The components of the primary outcome and quality of life were similar in the groups.

In an accompanying editorial,2 Dr Rod Passman (Northwestern University Feinberg School of Medicine, Chicago, USA) says that the study “makes an important contribution to the care of the growing number of patients with permanent AF”. He adds: “On a grander scale, the current analysis provides yet another example of how seemingly logical treatment strategies fail under the scrutiny of a rigorous clinical trial.”


1. Groenveld HF, Tijssen JGP, Crijns HJGM, et al. Rate control efficacy in permanent atrial fibrillation: successful and failed strict rate control against a background of lenient rate control data from RACE II (Rate Control Efficacy in Permanent Atrial Fibrillation). J Am Coll Cardiol 2013;61:741–8.

2. Passman R. Rate Control for permanent atrial fibrillation – a race (II) worth running? J Am Coll Cardiol 2013;61:749–51.

Published on: February 28, 2013

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    None Found


  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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