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Cost-Effectiveness of Rate vs. Rhythm Control for Afib

In the AFFIRM trial, rate control was more cost-effective, but many patients with atrial fibrillation don't fit the AFFIRM profile.

In the AFFIRM trial, elderly patients (mean age, 70; 61% men) with minimally symptomatic atrial fibrillation (AF) and high risk for stroke were randomized to either a rate-control or a rhythm-control strategy. Rates of mortality and of a combined cardiovascular endpoint were similar with the two strategies (Journal Watch Cardiology Jan 10 2003). Now, researchers have used the AFFIRM data (mean follow-up, 3.5 years) to retrospectively compare the strategies' cost-effectiveness from the perspective of a third-party payer.

Overall resource use was significantly lower in the rate-control group than in the rhythm-control group, with the most notable differences in hospital days, short-stay/emergency department visits, and cardioversions. The incremental per-person cost of rhythm control versus rate control was assessed in three separate scenarios: a "most likely" base-case scenario, a low-estimate scenario, and a high-estimate scenario. In all three, rhythm control had substantial incremental per-person costs over rate control: US$5077, $2189, and $5481, respectively. Not only was the incremental cost higher with rhythm control, but the incremental effect (i.e., mean survival) was also slightly worse with that strategy than with rate control.

Comment: Over a wide range of assumptions, rate control was a more cost-effective strategy than rhythm control in elderly patients with minimally symptomatic atrial fibrillation at high risk for stroke who would have been candidates for either strategy. For patients who fit this profile, rate control (plus appropriate anticoagulation therapy) appears to be the strategy of choice. However, an accompanying editorial reminds us not to generalize the findings to younger patients with lone AF, and a perspective piece mentions that some subgroups (e.g., patients with highly symptomatic AF and those with severe heart failure) might be better off with a sinus-rhythm strategy.

— Joel M. Gore, MD

Published in Journal Watch Cardiology November 26, 2004

Citation(s):

Marshall DA et al. Cost-effectiveness of rhythm versus rate control in atrial fibrillation. Ann Intern Med 2004 Nov 2; 141:653-61.

• Original article (Subscription may be required)
• Medline abstract (Free)

Bahnson TD and Grant AO. To be or not to be in normal sinus rhythm: What do we really know? Ann Intern Med 2004 Nov 2; 141:727-9.

• Original article (Subscription may be required)
• Medline abstract (Free)

Zimetbaum P and Josephson ME. Is there a role for maintaining sinus rhythm in patients with atrial fibrillation? Ann Intern Med 2004 Nov 2; 141:720-6.

• Original article (Subscription may be required)
• Medline abstract (Free)