EBQ:AFFIRM - Revision history

Danbot: Added Criticisms content

2026-03-21T22:39:31Z

Added Criticisms content

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	==Criticisms & Further Discussion==		==Criticisms & Further Discussion==
			*Enrolled an older population (mean age 70); results may not be generalizable to younger patients with symptomatic AF
			*Antiarrhythmic drugs used (primarily amiodarone and sotalol) have significant toxicities that may have offset benefits of sinus rhythm
			*Crossover rate was high: 37.5% of rhythm control patients were in AF at follow-up, and some rate control patients were in sinus rhythm
			*Anticoagulation could be stopped in the rhythm control group at physician discretion, which may have contributed to stroke events
			*Does not address whether rhythm control with newer, safer strategies (e.g., catheter ablation) would be beneficial
	==Funding==		==Funding==
	*National Heart, Lung, and Blood Institute (NHLBI)		*National Heart, Lung, and Blood Institute (NHLBI)

2026-03-21T22:36:42Z

Added Major Points, Criticisms, and Funding sections

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	'''Rhythm control for Afib offers no survival advantage over rate control, and rate control is potentially advantageous given the lower risk of adverse drug reactions with rhythm control medications.'''		'''Rhythm control for Afib offers no survival advantage over rate control, and rate control is potentially advantageous given the lower risk of adverse drug reactions with rhythm control medications.'''

	==Major Points==		==Major Points==
			*AFFIRM was the largest trial comparing rate control vs rhythm control strategies in atrial fibrillation
			*There was no survival advantage with rhythm control strategy; in fact, there was a trend toward increased mortality
			*Rhythm control was associated with more hospitalizations and adverse drug effects
			*The results challenged the prevailing assumption that maintaining sinus rhythm would improve survival
			*Anticoagulation should be continued regardless of rhythm control strategy, as most strokes occurred after warfarin was stopped or when INR was subtherapeutic
	==Study Design==		==Study Design==
	*Multicenter, randomized controlled trial		*Multicenter, randomized controlled trial
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	==Funding==		==Funding==
			*National Heart, Lung, and Blood Institute (NHLBI)
	==See Also==		==See Also==
	*[[EBQ:Ottawa_Aggressive_ED_Cardioversion_Protocol\|Ottawa Aggressive ED Cardioversion Protocol]]		*[[EBQ:Ottawa_Aggressive_ED_Cardioversion_Protocol\|Ottawa Aggressive ED Cardioversion Protocol]]

2016-03-22T13:53:30Z

Text replacement - "Category:Cards" to "Category:Cardiology"

2014-10-18T20:36:42Z

← Revisión anterior		Revisión del 20:36 18 oct 2014
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	\| fulltexturl=http://www.nejm.org/doi/full/10.1056/NEJMoa021328		\| fulltexturl=http://www.nejm.org/doi/full/10.1056/NEJMoa021328
	\| pdfurl=http://www.nejm.org/doi/pdf/10.1056/NEJMoa021328		\| pdfurl=http://www.nejm.org/doi/pdf/10.1056/NEJMoa021328
			\| status=Under Review
	}}		}}

2014-10-17T14:52:19Z

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	==Funding==		==Funding==

			==See Also==
			*[[EBQ:Ottawa_Aggressive_ED_Cardioversion_Protocol\|Ottawa Aggressive ED Cardioversion Protocol]]
			*[[EBQ:48hr_Cardioversion_for_Afib\|48hr Cardioversion for Afib]]

	==Sources==		==Sources==

2014-10-17T05:49:33Z

Affirm

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	===Primary Outcome===		===Primary Outcome===
	*Overal mortality		*Overal mortality at 5 years
			**Rhythym control 23.8%
			**Rate control 21.3%
			**Hazard ratio of 1.15 for rhythm control group- not statistically significant (p=0.08)

	===Secondary Outcomes===		===Secondary Outcomes===
	*Death		*Composite of:
	*Disabling stroke		**Death
	*Disabling anoxic encephalopathy		**Disabling stroke
	*Major bleeding		**Disabling anoxic encephalopathy
	*Cardiac arrest		**Major bleeding
			**Cardiac arrest
			*No difference between the two groups

	===Subgroup analysis===		===Subgroup analysis===

2014-10-17T05:38:56Z

Outcomes

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	===Primary Outcome===		===Primary Outcome===
			*Overal mortality


	===Secondary Outcomes===		===Secondary Outcomes===
			*Death
			*Disabling stroke
			*Disabling anoxic encephalopathy
			*Major bleeding
			*Cardiac arrest



	===Subgroup analysis===		===Subgroup analysis===



	==Criticisms & Further Discussion==		==Criticisms & Further Discussion==

2014-10-17T05:34:34Z

Affirm

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	*Unable to immediately start therapy after randomization		*Unable to immediately start therapy after randomization

	==Interventions==		==Interventions==
			*'''Rhythm control group''' attempted to maintain sinus rhythm. Antiarrhythmic drugs including: amiodarone, disopyramide, flecainide, moricizine, procainamide, propafenone, quinidine, sotalol, and combinations of the drugs were all possible. Treating physicians were allowed to choose the drug of their choice. Cardioversion was allowed as necessary.
			:
			*'''Rate control group''' attempted to maintain heart rate of 80 bpm or less while resting and 110 bpm or less with walking. Beta blockers, calcium-channel blockerrs, digoxin or combinations of the drugs were allowed. Again treating physicians could chose the drug of their choice.
			*Non-pharmacologic interventions such as ablation and pacing could be pursued after the failure of at least 2 drugs from either treatment group
			*INR of 2-3 was anticoagulation goal
			**Rhythm control group had the option of discontinuing anticoagulation if sinus rhythm was maintained for at least 4 consecutive weeks
			**Rate control group was maintained on anticoagulation

	==Outcomes==		==Outcomes==

2014-10-17T05:10:40Z

Affirm trial

@@ Línea 28: / Línea 28: @@
 ==Population==
 ===Patient Demographics===
 ===Inclusion Criteria===
+*Age 65 or older or risk factors for stroke or death
 ===Exclusion Criteria===
 ==Interventions==

2014-10-16T23:57:30Z

AFFIRM

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	==Clinical Question==		==Clinical Question==
	Which is better for treating atrial fibrillation, rate control allowing Afib at a lower heart rate, or rhythm control by maintaining sinus rhythm?		'''Which is better for treating atrial fibrillation, rate control allowing Afib at a lower heart rate, or rhythm control by maintaining sinus rhythm?'''

	==Conclusion==		==Conclusion==