Author + information
- Received July 25, 2018
- Accepted August 23, 2018
- Published online February 18, 2019.
- Ryan Kipp, MDa,b,
- Mariam Askari, BSc,
- Jun Fan, MSc,
- Michael E. Field, MDd,e and
- Mintu P. Turakhia, MD, MASc,f,g,∗ ()
- aDivision of Cardiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- bDivision of Cardiology, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
- cVeterans Affairs Palo Alto Health Care System, Palo Alto, California
- dDivision of Cardiology, Medical University of South Carolina, Charleston, South Carolina
- eDivision of Cardiology, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina
- fDepartment of Medicine, Stanford University School of Medicine, Stanford, California
- gCenter for Digital Health, Stanford University School of Medicine, Stanford, California
- ↵∗Address for correspondence:
Dr. Mintu Turakhia, VA Palo Alto Health Care System, Stanford University, 3801 Miranda Avenue—111C, Palo Alto, California 94304.
Objectives In this study the authors investigated effectiveness and safety of an initial treatment strategy with class IC or class III antiarrhythmic drugs (AAD) for newly diagnosed atrial fibrillation (AF) or atrial flutter (AFL).
Background There is limited evidence to guide optimal AAD selection for rhythm control in newly diagnosed AF/AFL.
Methods Using data from TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF), the authors performed a retrospective cohort study of patients with AF/AFL from 2004 to 2014 and class IC or class III AAD prescription within 90 days following diagnosis. Patients with prior myocardial infarction, heart failure, or end-stage renal disease were excluded. Inverse probability treatment weighted propensity scores were used to evaluate the association of AAD class on hospitalization and cardiovascular events. To evaluate residual confounding, falsification outcomes were evaluated.
Results A total of 230,762 patients developed newly diagnosed AF/AFL during the study period. Of those, 3,973 patients (1.7%) were prescribed class IC and 6,909 (3.0%) were prescribed class III AAD. Median follow-up was 4.9 years. After inverse probability treatment weighted adjustment, class IC medications were associated with lower risk of hospitalizations for AF/AFL (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.73 to 0.81), cardiovascular disease (HR: 0.78; 95% CI: 0.75 to 0.81), heart failure (HR: 0.70; 95% CI: 0.64 to 0.76), and lower incidence of ischemic stroke (HR: 0.74; 95% CI: 0.65 to 0.85). Similar results were found in CHADS2 (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke, Transient Ischemic Attack, or Thromboembolism) 0 or 1 and CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke, Transient Ischemic Attack, or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex) 0 or 1 subgroups. Falsification analyses for outcomes of urinary tract infection, pneumonia, and hip fracture were generally nonsignificant.
Conclusions Prescription of class IC AAD as initial treatment for newly diagnosed AF/AFL, compared with prescription of class III AAD, may be associated with lower risk of hospitalization and cardiovascular events.
Dr. Turakhia has received research grants from Janssen Pharmaceuticals, Medtronic Inc., AstraZeneca, Veterans Health Administration, Cardiva Medical Inc., Apple, American Heart Association, and Bristol-Myers Squibb; other research support from AliveCor Inc., Amazon, Zipline Medical Inc., iBeat Inc., iRhythm Technologies Inc.; and honoraria from Abbott, Medtronic Inc., Boehringer Ingelheim, Precision Health Economics, iBeat Inc., Akebia, Cardiva Medical Inc., and Medscape/theheart.org; and serves as an advisor to iRhythm Technologies Inc. and AliveCor Inc.
All the authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received July 25, 2018.
- Accepted August 23, 2018.
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