Lenient vs. strict rate control in patients with atrial fibrillation and heart failure: a post-hoc analysis of the RACE II study

It is unknown whether lenient rate control is an acceptable strategy in patients with AF and heart failure. We evaluated differences in outcome in patients with AF and heart failure treated with lenient or strict rate control. This post-hoc analysis of the RACE II trial included patients with an LVEF 40 at baseline or a previous hospitalization for heart failure or signs and symptoms of heart failure. Primary outcome was a composite of cardiovascular morbidity and mortality. Secondary endpoints were AF-related symptoms and quality of life. Two hundred and eighty-seven (46.7) of the 614 patients had heart failure. Patients with heart failure had significantly higher NT-proBNP plasma levels, a lower LVEF, and more often used ACE inhibitors, ARBs, and diuretics. At 3 years follow-up, the primary outcome occurred more frequently in patients with heart failure (16.7 vs. 11.5, P 0.04). In heart failure patients, the estimated cumulative incidence of the primary outcome was 15.0 (n 20) in the lenient and 18.2 (n 26) in the strict group (P 0.53). No differences were found in any of the primary outcome components, in either heart failure hospitalizations [8 (6.1) vs. 9 (6.8) patients in the lenient vs. strict group, respectively], symptoms, or quality of life. In patients with AF and heart failure with a predominantly preserved EF, the stringency of rate control seems to have no effect on cardiovascular morbidity and mortality, symptoms, and quality of life.