Lenient rate control is just as effective as strict rate control in AF, and has the added advantage of being more convenient for patients and physicians as well, according to results of the RACE II (Rate Control Efficacy in Permanent Atrial Fibrillation) trial presented here in Atlanta at the ACC and published simultaneously in the New England Journal of Medicine.
RACE II randomized 614 patients with permanent AF to a strategy of strict rate control (resting heart rate < 80 bpm and heart rate during moderate exercise <110 bpm) or lenient rate control (resting heart rate < 80 bpm). At 3 year followup, the primary composite endpoint (CV death, hospitalization for HF, stroke, systemic embolism, bleeding, and life-threatening arrhythmic events) was reached in 12.9% of the lenient-control group versus 14.9% in the strict control group, which met the prespecified noninferiority margin. The heart rate target was reached in more patients in the lenient control group than in the strict-control group (97.7% vs 67%, p<0.001), and there were fewer total visits in the lenient control group.
The investigators concluded that “lenient rate control is as effective as strict rate control” and that “for both patients and health care providers, lenient rate control is more convenient, since fewer outpatient visits and examinations are needed.”
In an accompanying editorial in the New England Journal of Medicine, Paul Dorian wrote that the RACE II investigators “have made an important contribution to our understanding of the potential benefits and risks of the current guideline-recommended approach to ventricular rate control in patients with persistent atrial fibrillation.”
Dorian found “no indication that there was any clinical benefit to strict rate control,” though he pointed out the possibility that a benefit of strict control might become apparent after many years. The study, he said, “does not suggest that ventricular rate is not needed, only that the conventional therapeutic target needs to be reassessed.”
He concluded that “treating a laboratory test is not a good substitute for targeting overt clinical outcomes” and “that it is better to treat the patient and not the electrocardiogram.”
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