Concurrent DOAC and rate control therapy in atrial fibrillation: nationwide time-dependent outcome analysis
R Arbel, M Haim, R Sergienko, Y Raz, B RenkosinskiAbstract
Background
The 2024 ESC Guidelines for atrial fibrillation emphasise anticoagulation for stroke prevention and recommend rate control primarily for symptom management or prevention of tachycardia-induced cardiomyopathy. Whether rate control therapy confers additional prognostic benefit in anticoagulated patients remains uncertain.
Purpose
To test the hypothesis that in the contemporary DOAC era, concurrent rate control therapy would be independently associated with lower major adverse cardiovascular events (MACE) beyond anticoagulation alone.
Methods
We conducted a retrospective cohort study using electronic health record data from Clalit Health Services, including all patients with a diagnosis of AF since 2014. The primary outcome was a composite MACE (cardiovascular death, myocardial infarction, ischaemic stroke). DOAC and rate control medication use were treated as time-varying exposures in Cox proportional hazards models. Models were adjusted for age, sex, socioeconomic status, baseline blood pressure and lipid levels, heart failure, chronic kidney disease, diabetes, hypertension, malignancy, prior stroke, and peripheral vascular disease.
Results
84,817 patients met the inclusion criteria. DOAC therapy was independently associated with reduced MACE (adjusted HR 0.78; 95% CI 0.74–0.81; P < 0.001). Rate control medication use was independently associated with lower MACE (HR 0.92; 95% CI 0.88–0.97; P < 0.05).
Conclusions
In this large, real-world AF cohort treated in the DOAC era, rate-control therapy was associated with lower MACE than anticoagulation alone. These findings raise the question of whether rate-control strategies may confer prognostic benefit in selected patients, a hypothesis that warrants prospective evaluation.