ESC 2017 - Barcelona

Risk factor-driven upstream atrial fibrillation therapy improves sinus rhythm maintenance (RACE 3)

Presented at the ESC congress 2017 by: Isabelle C. van Gelder (Groningen, The Netherlands)

Background

Maintenance of sinus rhythm is difficult, since risk factors, diseases underlying atrial fibrillation (AF) and AF itself cause atrial remodelling. Therefore, early intervention with atrial remodelling may prevent progression of AF.

In RACE 3 (Routine Versus Aggressive Upstream Rhythm Control for Prevention of Early Atrial Fibrillation in Heart Failure), early intervention (median 3 months AF) by risk factor-driven upstream therapy was compared with conventional therapy for effectivity, feasibility and safety in improving maintenance of sinus rhythm in 250 patients with symptomatic but early persistent AF and mild moderate heart failure (HF) during a 1-year follow-up.

After causal treatment of AF or HF, randomization took place. The upstream therapy group received: 1) cardiac rehabilitation including physical activity, dietary restrictions, and regular counselling on drug adherence, exercise maintenance and dietary restrictions; 2) mineralocorticoid receptor antagonists; 3) statins; and 4) angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers. After three weeks, all patients underwent electrical cardioversion and sinus rhythm (primary endpoint) was assessed with continuous 7-day Holter monitoring during the last week of the study. Secondary endpoints included atrial size, left ventricular function, exercise capacity, hospitalization for heart failure and other reasons, mortality, quality of life, and side effects of upstream therapies.

Main results

• Risk factor-driven upstream therapy proved to be superior in maintaining sinus rhythm: 75% of patients were in sinus rhythm after 1 year compared to 63% of patients that received conventional therapy (OR 1.77, 95% confidence limit 1.11, P=0.021).
• The change from baseline to 1-year in systolic and diastolic blood pressure, NT-proBNP levels and LDL levels were significantly different between treatment arms and larger in the risk factor-driven arm. On the other hand, left ventricular ejection fraction (LVEF), BMI and left atrial volume were not significantly different.

Conclusion

The RACE 3 study shows that risk factor-driven upstream therapy, including treatment of risk factors and change of lifestyle, is effective and feasible to improve maintenance of sinus rhythm in patients with early persistent AF and HF. These results may contribute to the shift in focusing on risk factor modification to improve outcomes for AF patients.

In a discussion during the press conference, Van Gelder was asked how practical it is to catch patients with early AF. She noted that today, patients are screened for AF and can therefore be immediately identified when they experience a first episode. They can start directly reducing their risk factors.

She also noted that the effect on atrial remodelling lacked, probably as remodelling possibly starts way earlier than symptoms present.

- Our reporting is based on the information provided at the ESC congress -