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Broad, Early AF Risk-Factor Intervention Preserves Sinus Rhythm: RACE-3

A broad-scale risk-factor intervention program appeared to successfully keep atrial fibrillation (AF) at bay for up to a year after electric cardioversion compared with standard care in a randomized trial, a small one but one of the first to confirm such a benefit lately seen in a number of observational studies. The aggressive intervention in the trial"s patients with recent-onset persistent AF and mild to moderate heart failure included intensive drug therapy, dietary management, cardiac rehabilitation and other exercise, and counseling. Drug therapy emphasized aldosterone inhibitors and other blood-pressure–lowering agents but also included statins.

Patients following the intervention showed a 76% greater likelihood of being in sinus rhythm at 12 months compared with those managed conventionally. Their significant reductions in natriuretic peptides during the trial were not associated with improvements in adverse atrial remodeling. The odds ratio (OR) for the primary end point of sinus rhythm at 1 year, assessed by continuous 7-day Holter monitoring read at a core lab, was 1.765 (P=0.021) for superiority in the intervention group.

The trial follows a number of mostly small observational studies pointing to a salutary effect from exercise and lifestyle changes on AF and its symptoms or need for AF ablation, including LEGACY and REVERSE-AF, which saw benefits from healthy-eating and weight-loss interventions, and CARDIO-FIT, which correlated improved AF outcomes with greater cardiorespiratory fitness.

It also supports the development of comprehensive AF prevention and management efforts similar to HF disease management programs, to increase focus on the arrhythmia"s causes and counter the predominant way AF is approached clinically. Everyone wants to focus on the arrhythmia, on performing an ablation, but they forget the associated conditions.

Van Gelder IC et al. Routine versus aggressive upstream rhythm control for prevention of early atrial fibrillation in heart failure, the RACE 3 study. European Society of Cardiology 2017 Congress. August 27, 2017. Abstract 2128.