Personalized rate control treatment for atrial fibrillation: a prospective case-control study on the use of diltiazem

Abstract Funding Acknowledgements Type of funding sources: None. Background Recent ESC Atrial Fibrillation guidelines introduced some changes in the options for rate control, such as the possibility to combine beta-blockers (BB) and non-dihydropyridine calcium channel blockers (NDCC), to address the need of personalized pharmacologic rate control strategy for AF. However, there are limited data on this topic. Purpose The aim of our study was to explore the prognostic impact of a personalized therapy (PT) for rate control, including the use of NDDC in patients with heart failure (HF) or in combination with BB, compared to standard rate control therapy (ST) as defined by previous ESC guidelines. Methods This is a single centre prospective observational registry on patients referred to our University Hospital for the management of AF between October 2013 and February 2019. Results We enrolled 1112 patients on exclusive rate control treatment, 125 (11.2%) were identified as patients with PT and 987 (88.8%) were on ST. In the PT group, 93/125 (74.4%) patients were prescribed BB + NDCC (±digoxin), while 85/125 (68.0%) were HF patients prescribed with NDCC, diltiazem in all cases. The mean age of patients was 73.5±12.0 years and 72.5±12.7 years in ST and PT groups, respectively. The two cohorts were homogeneous in terms of male prevalence, left ventricular ejection fraction and CHA2DS2-VASc score; while, HF was more frequent in PT group both in terms of patients with NYHA class ≥2 (41.3% in ST vs. 64.8% in PT, p<0.001) and prescription of diuretics (72.2% in ST vs. 88.0% in PT, p<0.001). Patients treated with PT had no difference in one-year overall survival compared to those with a ST (Figure 1 A). Notably, patients with HF in ST had a worse prognosis (p<0.001). (Figure 1 B) Conclusions Our results suggest a potential outcome benefit of NDCC for rate-control in AF patients, either alone or in combination with BB, also in selected patients with HF. Future controlled studies are needed to confirm our findings, and to identify subjects with higher benefit from such personalized rate-control strategies.