Chronic atrial fibrillation – rate control is more cost-effective

Several years ago a colleague and I conducted a spirited debate at Grand Rounds on the question of whether we should try to convert chronic atrial fibrillation to normal sinus rhythm. I took the side of using rate control (for symptoms) and anticoagulation (to decrease stroke rate). Subsequent studies have confirmed my arguments.

This CME (from Medscape) describes a cost-effectiveness analysis which appears in the current Annals of Internal Medicine. If you care for atrial fibrillation (and all generalists do) this article has great worth – Rate Control Is More Cost-Effective Than Rhythm Control of Atrial Fibrillation

Rate control was associated with a mean survival gain of 0.08 year (P = .10), use of fewer resources (hospital days, pacemaker procedures, cardioversions, and short-stay and emergency department visits), and a mean cost savings of $5,077 per person compared with rhythm control (range, $2,189 – $5,481 per person). Over a wide range of cost assumptions, rhythm control was more costly and less effective than rate control in 95% of the bootstrap replicates.

Study limitations include resource use limited to key items collected in AFFIRM, assumptions made about medication use on the basis of routine clinical practice, possible misclassification of medications exposure, generalizability only to similar patient populations with AF, AFFIRM protocol allowing the use of several drugs and nonpharmacologic therapy, high crossover rates, assumptions regarding costs, and cost-effectiveness estimate based on survival rather than quality of life.

“Rate control is a cost-effective approach to the management of [AF] compared with maintenance of sinus rhythm in patients with [AF] similar to those enrolled in AFFIRM,” the authors write.