JACC: Rate control doesn't improve a-fib patients' life quality
Permanent atrial fibrillation (AF) patients may be at a loss when it comes to quality of life. A study published in the Oct. 18 issue of the Journal of American College of Cardiology showed that rate control did not affect or improve quality of life; however, symptoms, female sex, older age and disease severity were shown to worsen quality of life in these patients.

“Quality of life (QOL) is reduced in patients with AF compared with healthy subjects,” Hessel F. Groenveld, MD, of the University Medical Center Groningen, the Netherlands, and colleagues wrote. “Restoration and maintenance of sinus rhythm improve QOL, but sinus rhythm can be maintained in a minority of patients.”

To better understand how rate control influences QOL, Groenveld and colleagues conducted a substudy of the RATE II (Rate Control Efficacy in Permanent Atrial Fibrillation II) trial, which studied 614 permanent AF patients who were randomized to lenient (resting heart rate of <110 beats/min) or strict (resting heart rate <80 beats/min, heart rate during moderate exercise <110 beats/min) rate control.

During the study, QOL was evaluated in 437 patients using the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire, AF severity scale and Multidimensional Fatigue Inventory-20 at baseline, one year and end of the study.

The study had a median follow-up of three years and patients had a mean age of 68 years; 66 percent were male.

The researchers reported that 58 percent of patients experienced AF symptoms at baseline. By the end of the study, 48 percent of patients experienced AF symptoms: 32 percent experienced dyspnea, 25 percent experienced fatigue and 11 percent experienced palpitations. Additionally, it was reported that SF-36 scales were comparable between the lenient and strict rate control groups.

However, low QOL scores were associated with the presence of symptoms, diabetes, older age and female sex. High AF severity scale scores were shown to be associated with symptoms of AF and female sex. While symptoms at baseline, younger age and less severe underlying disease were associated with QOL improvements, cardiovascular endpoints were also associated with worsening QOL.

“The present analysis of the RACE II study suggests that stringency of rate control does not affect QOL during treatment of patients with permanent AF,” Groenveld et al wrote. “Compared with healthy subjects, QOL is reduced in patients with AF.

“Why do heart rate and stringency of heart rate control not affect QOL in AF?” the authors asked. They wrote that one explanation could be the fact that permanent AF patients may lack typical AF symptoms.

“Notwithstanding these factors, presence of symptoms was related to QOL as well as changes in QOL over time, and the latter was not affected by stringency of rate control,” the authors wrote. “Obviously, in highly symptomatic patients with uncontrolled heart rate well above 110 beats/min at rest, rate control would significantly affect QOL.”

For practitioners, the main goal of AF management is to reduce a patient’s symptoms, Paul Dorian, MD, and Andrew C.T. Ha, MD, of St. Michael’s Hospital and Toronto General Hospital, respectively, wrote in an accompanying editorial. “For most patients, this will involve slowing of the rapid and irregular ventricular rate that usually accompanies AF, either as the initial or the exclusive goal of treatment (in addition to the crucially important need to assess stroke risk and treat appropriately).

“Components of QOL are by definition subjective, and understanding the impact of the AF condition in a particular patient requires the disentanglement of those aspects of the illness that are directly or indirectly related to AF from other symptoms or difficulties related to coexisting illnesses (e.g., heart failure, pulmonary disease), symptoms or mental states associated with other health-related problems,” Dorian and Ha wrote.

Dorian and Ha offered that catheter ablation may work to improve QOL. The authors wrote that the study by Groenveld et al showed that it is insufficient “to merely examine the electrocardiogram of patients in AF to assess the impact of their illness on their well-being.

“For example, a resting ventricular response rate in AF of 100 beats/min does not necessarily imply the patient is worse off than if his or her heart rate was 60 beats/min and should not necessarily prompt the practitioner to intensify rate control therapy.”

Dorian and Ha concluded that in terms of AF treatments, it may be useful to take the advice of Hippocrates: “It is far more important to know what person the disease has than what disease the person has.”