TABLE 27.

Randomized Trials of Rhythm Control in HF

Study/ Author (y)	No. Pts.	Inclusion	Exclusion	Intervention	Primary Outcome	Death and Hospitalization	Death	Hospitalizations	Reduction in AF	LVEF	QOL	6MWT	Peak VO2 Max	BNP
Roy (2008)60	1376	LVEF <35%, CHF		AAD (primarily amiodarone) vs rate control	Cardiovascular mortality was no different between rhythm vs rate control	No change	No difference	No difference
MacDonald (2011)8	41	Persistent AF; LVEF <35%, CHF II-IV	PAF; QRS >150	RF to medical therapy	Similar increase in CMR LVEF			No difference	Improved with RF	Improved	No change	No change
ARC-HF: Jones (2013)6	52	Persistent AF; LVEF <35%, CHF		RF to medical therapy	Improvement in peak VO2 with RF	No change	No difference	No difference		No change	Improved with RF	No change	Improved
CAMTAF (2014)5	50	Persistent AF; LVEF <50%; CHF		RF to medical therapy	LVEF significantly improved with RF	No change	No difference			Improved	Improved with RF		Improved
AATAC (2016)4	203	Persistent AF; LVEF <40%, CHF II-III		RF to amiodarone	At 24 mo, RF patients more likely to be in NSR	Improvement with RF	Improved	Improved		Improved	Improved with ablation	Improved
CAMERA MRI (2017)12	66	Persistent AF; LVEF <45%, CHF II-III; idiopathic CM		RF to medical therapy	Improved LVEF with RF					Improved	No change	No change		Improved
CASTLE-AF (2018)9	363	PAF or persistent AF; LVEF <36%, CHF II-IV and ICD		RF to medical therapy	Composite of death and hospitalization lower with RF	Improvement with RF	Improved	Improved		Improved
AMICA (2019)7	140	Persistent AF; LVEF <36%		RF to medical therapy	No difference in change in LVEF					No change	No change	No change		No change
CABANA substudy (2021)14	778	Clinical HF (largely HFpEF)		RF to medical therapy	Decrease in composite of MACE		Improved		Improved with RF		Improved with RF
RAFT-AF (2022)11	411	≥4 PAF/y or persistent AF, NYHA class II or III HF, elevated pro-BNP		RF to medical therapy	No difference in change in mortality/HF	No difference in change in mortality/HF	No change	No change	Improved with RF	Improved with RF	Improved with RF	Improved with RF		Improved with RF
Meta-analysis-Turagam (2019)13	775			RF to medical therapy			Improved	Reduced		Improved	Improved	Improved	Improved
Meta-analysis-Chen (2020)3	1112			RF to medical therapy			Improved	Reduced	Improved with RF	Improved	Improved
Meta-analysis-Pan (2021)10	775			RF to medical therapy			Improved	Reduced		Improved	Improved	Improved

AAD indicates antiarrhythmic drug; AATAC, Ablation vs Amiodarone for Treatment of Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted ICD/CRTD; AF, atrial fibrillation; AMICA, Atrial Fibrillation Management in Congestive Heart Failure With Ablation; ARC-HF, A Randomised Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Chronic Heart Failure; BNP, brain natriuretic peptide; CABANA, Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation; CAMERA MRI, Catheter Ablation versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction-an MRI-Guided Multi-centre Randomised Controlled Trial; CAMTAF, Catheter Ablation Versus Medical Treatment of AF in Heart Failure; CASTLE-AF, Catheter Ablation versus Standard Conventional Therapy in Patients with Left Ventricular Dysfunction and Atrial Fibrillation; CHF, congestive heart failure; CM, cardiomyopathy; CMR, cardiac magnetic resonance: HF, heart failure; HFpEF, heart failure with persistent ejection fraction; ICD, implantable cardioverter-defibrillator; LVEF, left ventricular ejection fraction; MACE, major adverse cardiovascular events; NSR, normal sinus rhythm; NYHA, New York Heart Association; PAF, paroxysmal atrial fibrillation; QOL, quality of life; RAFT-AF, Rhythm Control–Catheter Ablation With or Without Anti-arrhythmic Drug Control of Maintaining Sinus Rhythm Versus Rate Control With Medical Therapy and/or Atrio-ventricular Junction Ablation and Pacemaker Treatment for Atrial Fibrillation; RF, radiofrequency; VO₂ max, maximal oxygen consumption; 6MWT, 6-minute walk test.