Risk Factor-Driven Upstream Therapy Improves Sinus Rhythm for AFib Patients

The novel risk factor-driven upstream rhythm control therapy was found to be effective and safe when it comes to improving sinus rhythm in patients with early short-lasting atrial fibrillation (AF) and heart failure (HF), according to results presented at the European Society of Cardiology.

The Routine versus Aggressive upstream rhythm Control for prevention of Early persistent atrial fibrillation in heart failure (RACE) randomized study allocated 250 patients with early mild to moderate heart failure to conventional therapy either with or without 4 additional risk factor-driven upstream treatments.

At the 1-year follow-up point, sinus rhythm was present in 75% of patients (n=89) in the upstream arm compared to 63% (n=79) in the conventional group (p=0.021). Between the 2 arms, there was no difference in the number of electrical cardioversions (ECV) or antiarrhythmic drug (AAD) use.

In regard to patients with repeat ECVs, 56% of the upstream arm achieved rhythm control compared to 51% in the conventional arm. The upstream arm also outperformed the conventional arm in patients with AADs and atrial ablations, 45% to 43% and 4% to 2%, respectively.

“The RACE 3 study demonstrates 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,” Isabelle Van Gelder, MD, professor of medical sciences at the University of Groningen said at the presentation.

The upstream therapy included cardiac rehabilitation that included physical activity, dietary restrictions, and counseling; mineralocorticoid receptor antagonists; statins; and angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers.

Therapies started 3 weeks before electrical cardioversion and continued for 12 months. The upstream therapies also showed lower rates of composite cardiovascular morbidity and mortality (16% compared to 17%).

“Upstream rhythm control, including meticulous treatment of risk factors and change of lifestyle, is effective, feasible and safe in improving maintenance of sinus rhythm in patients with early short-lasting AF and early mild to moderate heart failure,” Michiel Rienstra (pictured), MD, cardiologist and clinical director of cardiology at the University Medical Centre Groningen, said in a statement. "The upstream therapies also improved treatment of cardiovascular risk factors.”

For most patients with AF, it is caused by comorbidities like hypertension, heart failure, and obesity, and despite available treatment options, long-term upkeep of sinus rhythm is burdensome. Upstream therapy could be able to modify atrial remodeling — which causes AF progression.

"The effect of upstream therapy on reduction of risk factors and cardiovascular diseases, instead of atrial remodeling, was favorable,” Gelder said. “Therefore, our study may contribute to the shift to focus on risk factor modification to improve AF outcomes.”

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