Rhythm control for atrial fibrillation in patients with end-stage or chronic kidney disease

Abstract Background Although early rhythm control (ERC) improves cardiovascular outcomes in patients with atrial fibrillation (AF), its use in patients with chronic kidney disease (CKD) remains challenging. Purpose This study aimed to investigate the benefits and risks of ERC in CKD. Methods This population-based cohort study included 5,224 patients with AF (65% male, median age 63 years) with CKD stage III–IV (n=3564) and end-stage renal disease (ESRD, n=1660), who underwent ERC or rate control between 2005 and 2015. The primary outcome consisted of cardiovascular death, ischemic stroke, heart failure-related hospitalization, and acute myocardial infarction. Results During a median follow-up of 3.5 years, ERC, compared to rate control, was associated with a reduced risk of the primary outcome (hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.74–0.98) without increasing the composite safety outcome in CKD stage III–IV (HR 0.99, 95% CI 0.86–1.13). Among patients with ESRD, the primary outcome did not differ between ERC and rate control (HR 0.97, 95% CI 0.81–1.17) but ERC was associated with an increased risk of composite safety outcome (HR 1.29, 95% CI 1.11–1.50), compared to rate control. However, considering the non-adherence to ERC, its comparative effectiveness on the primary outcome was observed in ESRD (HR 0.81, 95% CI 0.68–0.98). Additionally, ablation procedures did not increase the risk of composite safety outcome (HR 0.63, 95% CI 0.32–1.24). Conclusion ERC demonstrated a modest risk-benefit profile in ESRD compared to CKD stage III–IV. Randomized clinical trials should validate the efficacy of ERC, including ablation procedures, particularly in patients with ESRD.