Rate control in a fib – not too tight

Many articles in the NEJM seem arcane and eclectic to this blogger.  However, the best articles in this esteemed journal are really great.  So it is today with the early release of this article – "Lenient" as good as "strict" ventricular rate control in permanent AF: RACE-2 trial 

When pursuing a rate-control strategy in patients with "permanent" atrial fibrillation (AF), it's just as clinically effective and a good deal easier, for patient and doctor alike, to treat with beta blockers, calcium-channel blockers, and other agents until the resting heart rate is <110 bpm as to aim for <80 bpm, a prospective study suggests [1].

In the randomized Rate Control Efficacy in Permanent Atrial Fibrillation (RACE 2) trial, more patients were able to achieve the higher "lenient" heart-rate target than the lower "strict" target, and they required far fewer doctor visits. Yet symptoms attributable to AF and drug side effects were about as prevalent in one group as the other, and the lenient strategy was "noninferior" (p<0.001) to the strict approach for a composite primary end point that included CV death, heart-failure hospitalization, stroke, and other major events.

Actually there were more end points in the strict control group.

We live in an era in which we forget that medications carry impacts.  We focus too much on targets, too often ignoring the cost of reaching those targets.  A few examples should resonate with physician readers: tight glucose control in ICU patients; anemia in CKD; and now rate control in atrial fibrillation.

Too often we worry about numbers rather than patients.  This study should both guide our rate control targets in atrial fibrillation and remind us that treatments are rarely benign.  I welcome this study and its findings.  I will immediately adopt the findings.