Journal of the American College of Cardiology Vol. 43, No.

2, 2004
© 2004 by the American College of Cardiology Foundation ISSN 0735-1097/04/$30.00
Published by Elsevier Inc. doi:10.1016/j.jacc.2003.08.037

Effect of Rate or Rhythm Control on

Quality of Life in Persistent Atrial Fibrillation
Results From the Rate Control Versus
Electrical Cardioversion (RACE) Study
Vincent E. Hagens, MD,* Adelita V. Ranchor, PHD,† Eric Van Sonderen, PHD,† Hans A. Bosker, MD,‡
Otto Kamp, MD,§ Jan G. P. Tijssen, PHD,㛳 J. Herre Kingma, MD,¶ Harry J. G. M. Crijns, MD,#
Isabelle C. Van Gelder, MD,* for the RACE Study Group**
Groningen, Arnhem, Amsterdam, Nieuwegein, and Maastricht, the Netherlands
OBJECTIVES We studied the influence of rate control or rhythm control in patients with persistent atrial
fibrillation (AF) on quality of life (QoL).
BACKGROUND Atrial fibrillation may cause symptoms like fatigue and dyspnea. This can impair QoL.
Treatment of AF with either rate or rhythm control may influence QoL.
METHODS Quality of life was assessed in patients included in the Rate Control Versus Electrical
Cardioversion for Persistent Atrial Fibrillation (RACE) study (rate vs. rhythm control in
persistent AF). Rate control patients (n ⫽ 175) were given negative chronotropic drugs and
oral anticoagulation. Rhythm control patients (n ⫽ 177) received serial electrocardioversion,
antiarrhythmic drugs, and oral anticoagulation, as needed. Quality of life was studied using
the Short Form (SF)-36 health survey questionnaire at baseline, one year, and the end of the
study (after 2 to 3 years of follow-up). At baseline, QoL was compared with that of healthy
control subjects. Patient characteristics related to QoL changes were determined.
RESULTS Mean follow-up was 2.3 years. At baseline, QoL was lower in patients than in age-matched
healthy controls. At study end, under rate control, three subscales of the SF-36 improved.
Under rhythm control, no significant changes occurred compared with baseline. At study end,
QoL was comparable between both groups. The presence of complaints of AF at baseline, a
short duration of AF, and the presence of sinus rhythm (SR) at the end of follow-up, rather
than the assigned strategy, were associated with QoL improvement.
CONCLUSIONS Quality of life is impaired in patients with AF compared with healthy controls. Treatment
strategy does not affect QoL. Patients with complaints related to AF, however, may benefit
from rhythm control if SR can be maintained. (J Am Coll Cardiol 2004;43:241–7) © 2004
by the American College of Cardiology Foundation

Atrial fibrillation (AF) causes disabling symptoms like rate control in terms of QoL. The Pharmacological Inter-
fatigue, dyspnea, and palpitations. Additionally, patients vention in Atrial Fibrillation (PIAF) trial investigators
may perceive their arrhythmia as life-threatening or dis- demonstrated that the type of treatment (either rhythm
abling. As a result, quality of life (QoL) may be drastically control using cardioversion and antiarrhythmic drug treat-
reduced. Conceivably, normalizing the rhythm is beneficial ment or rate control, aiming at an adequate ventricular rate
(1). Ablation of atrioventricular conduction with implanta- during accepted AF) did not affect QoL (6). Follow-up was
tion of an artificial pacemaker was shown to improve QoL limited to one year, and rhythm control did not include
(2– 4). However, this invasive treatment is appropriate in serial cardioversions and serial antiarrhythmic drug treat-
problematic AF only. In the usual patient, amiodarone, ment. In this study, the Rate Control Versus Electrical
sotalol, or propafenone may enhance QoL, especially if Cardioversion for Persistent Atrial Fibrillation (RACE)
sinus rhythm (SR) is maintained (5). At present, it is not study, we analyzed QoL in patients randomized to rate or
well known whether rhythm control is indeed superior to rhythm control (1). The aim of this study was to determine:
1) QoL in patients with persistent AF, as compared with
that in age-matched healthy control subjects; 2) changes
From the *Department of Cardiology, University Hospital, Groningen; †Northern
Center for Healthcare Research, Groningen; ‡Department of Cardiology, Rijnstate over time, and to compare rhythm and rate control with
Hospital, Arnhem; §Free University Medical Center, Amsterdam; 㛳Academic Med- respect to these changes; and 3) to determine predictors
ical Center, Amsterdam; ¶St. Antonius Hospital, Nieuwegein (at present Inspector- (i.e., clinical characteristics) of improvement or a decrease in
General of Health Care of the Netherlands); and #University Hospital, Maastricht,
Netherlands.**Participants in the RACE for Persistent Atrial Fibrillation Study are QoL.
listed elsewhere (1). This study was supported by grants from the Center for Health
Care Insurance (OG96-047) and the Interuniversity Cardiology Institute, the METHODS
Netherlands, and by an unrestricted grant from 3M Pharma, the Netherlands. Drs.
Van Gelder and Crijns received lecture fees from 3M Pharma. Dr. Crijns is a Patient population. This study was performed in patients
consultant to Sanofi-Synthelabo and AstraZeneca.
Manuscript received March 25, 2003; revised manuscript received June 20, 2003, with persistent AF included in the RACE study (1). The
accepted August 11, 2003. study was approved by the institutional review boards of
242 Hagens et al. JACC Vol. 43, No. 2, 2004
Quality of Life in AF January 21, 2004:241–7

adverse events. For the present analysis, we included all 352

Abbreviations and Acronyms patients who completed the self-administered QoL ques-
AF ⫽ atrial fibrillation tionnaire at baseline, after one year, and at the end of
AFFIRM ⫽ Atrial Fibrillation Follow-up Investigation follow-up (end of study: at 24 months for 134 patients and
of Rhythm Management trial
CTAF ⫽ Canadian Trial of Atrial Fibrillation trial
at 36 months for 218 patients). Patients who died during
HF ⫽ heart failure the follow-up of RACE were not analyzed (18 patients in
NYHA ⫽ New York Heart Association the rate control and 18 patients in the rhythm control
PIAF ⫽ Pharmacological Intervention in Atrial group). Another 134 patients (63 rate and 71 rhythm
Fibrillation trial
QoL ⫽ quality of life
control patients) did not complete the QoL questionnaire at
RACE ⫽ Rate Control Versus Electrical either baseline, one year, or the end of the study and were
Cardioversion for Persistent Atrial excluded. All the excluded patients did not differ signifi-
Fibrillation trial cantly from included patients at baseline and follow-up.
SF-36 ⫽ Short-Form 36
SR ⫽ sinus rhythm
Patient characteristics at baseline are shown in Table 1.
Quality-of-life questionnaire. Quality of life was assessed
using the Medical Outcomes Study Short-Form 36 (SF-36)
each participating hospital, and all patients gave written, health survey questionnaire (7). The SF-36 is a standard-
informed consent. In the RACE study, we included 522 ized, validated, generic health survey that has been fre-
patients with recurrent persistent AF who were randomized quently used in arrhythmia studies. The SF-36 has been
to rate or rhythm control. It was shown that both strategies translated and validated in the Netherlands (8). It contains
were associated with a comparable rate of cardiovascular items to assess physical health (e.g., general health percep-

Table 1. Baseline Characteristics

Rate Control Group Rhythm Control Group
(n ⴝ 175) (n ⴝ 177)
Age (yrs) 68 ⫾ 9 68 ⫾ 8
Male gender 107 (61%) 119 (67%)
Total AF duration (days) 511 (14–14,909) 495 (1–8,513)
Duration present episode of AF (days) 33 (1–392) 36 (1–376)
Complaints of AF 129 (74%) 124 (70%)
Fatigue 75 (58%) 67 (54%)
Dyspnea 67 (52%) 59 (48%)
Palpitations 50 (39%) 43 (35%)
Heart rate at inclusion (beats/min) 91 ⫾ 20 90 ⫾ 20
Underlying diseases (%)
Coronary artery disease 22 28
Old myocardial infarction 12 17
Valvular disease 19 13
Mitral valve disease 14 11
Aortic disease 5 3
Aortic and mitral valve disease 0 1
Cardiomyopathy 11 6
History of hypertension 42 53
History of chronic obstructive lung disease 21 15
Diabetes mellitus 11 10
No heart disease 22 21
NYHA class for heart failure (%)
I 49 48
II 49 49
III 2 3
Previous ischemic thromboembolic complication 17 12
Stroke 5 4
Previous hemorrhagic complication 9 7
Echocardiographic parameters
Left ventricular end-diastolic diameter (mm) 53 ⫾ 7 52 ⫾ 7
Left ventricular end-systolic diameter (mm) 37 ⫾ 8 37 ⫾ 8
Fractional shortening (%) 31 ⫾ 9 30 ⫾ 10
Left atrial diameter, parasternal long axis (mm) 45 ⫾ 7 45 ⫾ 7
Left atrial diameter, apical view (mm) 64 ⫾ 8 63 ⫾ 8
Right atrial diameter, parasternal long axis (mm) 58 ⫾ 8 57 ⫾ 8
Data are presented as the mean value ⫾ SD, number (%) of subjects, median value (range), or percentage of subjects.
AF ⫽ atrial fibrillation; NYHA ⫽ New York Heart Association.
JACC Vol. 43, No. 2, 2004 Hagens et al. 243
January 21, 2004:241–7 Quality of Life in AF

tion, physical functioning, role limitations due to physical RESULTS

problems and bodily pain) and mental health (social func-
QoL at baseline. Quality of life at baseline did not differ
tioning, role limitations due to emotional problems, mental
between the 352 analyzed patients and the patients for
health, and vitality). The SF-36 scale, which measures
whom the baseline questionnaire was available but who had
change in health, is not considered in the analyses. The
to be excluded for missing follow-up questionnaires. Also,
items for general health perception and vitality measure their baseline characteristics were comparable (data not
both. Each scale is composed of a number of multiple- shown). At baseline, there were no significant differences in
choice questions, ranging in a stepwise fashion from im- QoL between the rate and rhythm control groups (Table 2).
paired/low QoL to not impaired/high QoL. For each of the At study entry, QoL was lower for our patients compared
eight subscales, scores are transformed to a scale ranging with a healthy, age-matched control group. Differences in
from 0 to 100, with lower scores representing a lower QoL. physical and emotional role limitations were highest
Complaints related to AF were assessed at each study (Fig. 1).
visit, using a standardized questionnaire attached to the case Low QoL scores for physical health at baseline (scores on
record form. Complaints at inclusion were assessed for the the subscales under the mean value ⫺ 1 SD) were more
current episode of AF before randomization. frequent among: 1) females (p ⬍ 0.01; physical functioning
Statistical analysis. At baseline, all patients were compared and physical role limitations); 2) patients whose age was
with a healthy, age-matched control group consisting of 172 under the median value of 69 years (p ⬍ 0.05; physical
Dutch subjects who served to validate the Dutch version of functioning); 3) patients with a duration of AF above the
the SF-36. At baseline, at one year, and at the end of the median of 32 days (p ⬍ 0.05; physical functioning); and 4)
study, the scores on all subscales of the SF-36 were patients with reduced exercise tolerance (New York Heart
compared between the rate and rhythm control groups. Association [NYHA] functional class II/III) (p ⬍ 0.05;
To analyze patient characteristics associated with low general health, physical functioning, role physical, and
QoL at baseline, patients with low scores (scores lower than bodily pain). Low QoL scores for mental health were more
the mean value ⫺ 1 SD) were identified. To assess the frequent among patients ⬎69 years old (p ⬍ 0.05; mental
relevance of changes in the different subscales over time, health and social functioning). Patients with complaints of
changes in the scores from baseline to the end of the study AF, especially fatigue (p ⬍ 0.05; general health, physical
were divided into relevant and irrelevant. For each of the functioning, physical role limitations, bodily pain, social
eight subscales, the relevance of a change in QoL was functioning, and vitality), and those with reduced fractional
defined according to the number of steps by which the shortening (p ⬍ 0.05; role physical, social functioning, and
patient improved or worsened on the multiple-choice ques- vitality) had a reduced score for both physical and mental
tions that comprised each SF-36 subscale. The following health parameters.
changes in QoL for the individual patient were regarded as Quality of life from baseline to study end. At 12-month
relevant and relied on the number of questions that com- follow-up in the rate control group, four subscales of the
SF-36 had improved (Table 2). At study end, three sub-
prised each SF-36 subscale: 1 step for role limitations due to
scales had significantly improved: role limitations due to
physical problems and for role limitations due to emotional
physical problems, social functioning, and mental health.
problems; 2 steps for social functioning and bodily pain; and
Physical functioning worsened over time.
3 steps for general health perception, physical functioning,
After one year of rhythm control therapy, QoL improved
mental health, and vitality. The effect sizes were calculated
on three subscales, including two scales measuring physical
according to Cohen (9) by dividing the differences in the
health. However, at the end of the study, no significant
mean QoL score by the pooled standard deviation to assess changes were present compared with baseline scores.
the change in QoL for each subscale within the randomized When the scores on the SF-36 subscales at 12-month
arm. Clinical correlates of a change in QoL, including follow-up and study end were compared between the rate
clinical baseline and follow-up characteristics, were deter- and rhythm control groups, no significant differences were
mined. Subanalysis was performed to determine whether found in any of the eight subscales (Table 2). The absolute
relevant QoL changes were correlated with randomized differences between the scores at baseline and study end
strategy. To examine changes over time for each SF-36 were not statistically different between rate and rhythm
scale, the method of repeated measures was performed. For control. The percentage of patients with a relevant increase
a comparison of scores between groups and with the control in follow-up was generally higher than that of patients with
group, the Student t test for independent variables was used. a relevant decrease in QoL over time; however, the effect
The univariate chi-square test and Student t test for sizes within each randomized strategy were small and always
independent variables, followed by multivariate stepwise below 0.25 (i.e., one-fourth of SD) (Table 2).
regression analyses, were performed to determine indicators The occurrence of complaints related to AF was compa-
of relevant QoL changes over follow-up. All analyses were rable between the rate and rhythm control groups over
performed on an intention-to-treat basis. follow-up. Fatigue and dyspnea were most common.
244 Hagens et al. JACC Vol. 43, No. 2, 2004
Quality of Life in AF January 21, 2004:241–7

Table 2. Short-Form 36 Quality-of-Life Scores

Effect Size Relevant Relevant
Change From (Baseline Increase From Decrease From
SF-36 Subscale Baseline to to Study Baseline to Baseline to
Strategy Baseline 12 Months Study End Study End‡ End) Study End (%) Study End (%)
General health
Rate 54 (19) 58 (18)* 57 (18) ⫹3 0.16 23 14
Rhythm 54 (18) 58 (20)* 54 (20) 0 0 19 16
Physical functioning
Rate 62 (24) 62 (23) 59 (25)*† ⫺3 ⫺0.12 14 22
Rhythm 64 (24) 67 (24)* 64 (27) 0 0 18 21
Role physical
Rate 45 (46) 59 (42)* 53 (44)* ⫹8 0.18 26 18
Rhythm 50 (44) 61 (43)* 55 (45) ⫹5 0.11 23 17
Bodily pain
Rate 80 (22) 81 (21) 79 (23) ⫺1 ⫺0.04 14 20
Rhythm 81 (21) 82 (22) 80 (22) ⫺1 ⫺0.05 16 15
Mental health
Rate 73 (18) 77 (18)* 76 (17)* ⫹3 0.17 25 14
Rhythm 74 (18) 76 (19) 76 (18) ⫹2 0.11 25 18
Social functioning
Rate 76 (24) 81 (21)* 81 (21)* ⫹5 0.22 26 13
Rhythm 78 (22) 79 (25) 80 (23) ⫹2 0.09 16 11
Role emotional
Rate 73 (41) 76 (38) 73 (39) 0 0 19 18
Rhythm 70 (42) 74 (39) 74 (38) ⫹4 0.10 24 17
Vitality
Rate 60 (22) 59 (20) 59 (21) ⫺1 ⫺0.05 16 19
Rhythm 60 (21) 62 (21) 62 (21) ⫹2 0.10 25 17
*p ⬍ 0.05 compared with baseline score. †p ⬍ 0.05 compared with 12-month score. ‡No significant differences between groups.
SF-36 ⫽ Medical Outcomes Study Short-Form 36.

Determinants of QoL changes. For the total study group, 0.005) at inclusion, and SR at the end of the study (p ⫽
we investigated which baseline (Table 1) and follow-up 0.003). In 23 patients (6.5%), QoL on five or more subscales
parameters were related to a relevant change in each deteriorated. No parameters were related to a significant
subscale of the SF-36 at study end. The follow-up para- decrease in QoL on five or more subscales.
meters were randomized strategy, underlying disease, For the rate control group alone, the presence of SR at
NYHA class for heart failure (HF), improvement or wors- study end resulted in a relevant improvement in QoL on five
ening of echocardiographic parameters (left ventricular and or more subscales (p ⫽ 0.002). However, the number of
atrial diameters, fractional shortening), presence of SR at patients who improved was small (5 of 17 patients with SR
study end, and occurrence of a severe adverse cardiovascular at study end in the rate control group). For the rhythm
event, including HF, thromboembolic complication, bleed- control group, younger age (p ⫽ 0.041), shorter duration of
ing, implantation of a pacemaker, or severe adverse effects of AF (p ⫽ 0.026), and presence of SR at end of the study led
medication. to a relevant QoL improvement (11 of 65 patients with SR
Stepwise regression analyses revealed that age ⬍69 years, at study end, p ⫽ 0.022). The number of electrical cardio-
complaints of AF (especially fatigue and dyspnea) at inclu- versions needed in these patients with SR at study end did
sion, a short duration of AF, and SR at the end of follow-up not have any association with QoL.
were determinants of relevant QoL improvement during There were no interactions between the determinants of
follow-up (Table 3; only determinants that were significant QoL and the randomized strategy, indicating that there
with use of multivariate analysis are shown). The type of were no subgroups of patients in whom either rate or
randomized strategy (rate or rhythm control) was not rhythm control is preferable.
associated with relevant changes.
A total of 35 patients (10%) showed a major improve-
DISCUSSION
ment in QoL, defined as relevant improvements on five or
more subscales of the SF-36. Characteristics (baseline and This study shows that patients with persistent AF have a
follow-up parameters) associated with improved QoL on lower QoL than their healthy age-matched controls. Fur-
five or more subscales were the same as those identified thermore, QoL did not change significantly during long-
using the stepwise regression analysis: younger age (⬍69 term rhythm control treatment, whereas during rate control
years, p ⫽ 0.020), shorter duration of AF (⬍32 days, p ⫽ treatment, minor changes occurred. However, there were no
0.005), presence of dyspnea (p ⫽ 0.048) or fatigue (p ⫽ differences in QoL between the rate control and rhythm
JACC Vol. 43, No. 2, 2004 Hagens et al. 245
January 21, 2004:241–7 Quality of Life in AF

Figure 1. Quality-of-life comparison between study patients at baseline and control subjects.*p ⬍ 0.05. Solid bars ⫽ RACE subjects (n ⫽ 352); open bars
⫽ control subjects (n ⫽ 172).

control groups at the end of follow-up. Finally, maintenance study, exercise tolerance and QoL were comparable between
of SR rather than the assigned treatment strategy was an both groups, even though a higher level of comorbidity was
important parameter for improvement of QoL. found in the AF group (11).
QoL in persistent AF. Compared with healthy volunteers, In the present study, impaired QoL at baseline predom-
QoL was significantly reduced in our patients. This is in inantly occurred in patients with complaints related to AF
accordance with Dorian et al. (10), who showed that (especially fatigue), patients with more severe underlying
patients with heart disease (either AF or HF or ischemic heart disease (NYHA class II/III HF and/or reduced
heart disease) had lower scores on the SF-36 subscales than fractional shortening), and females. About 80% of our
did healthy controls. However, this is in contrast to another patients had, apart from AF, underlying heart disease,
study in which a cohort of older ambulatory patients with which may have contributed significantly to their com-
chronic AF (mean age 76 years) was compared with an plaints and impaired QoL (10,12,13). Complaints were an
age-matched control group of patients in SR. In the latter important determinant of reduced physical and mental

Table 3. Determinants of Relevant Changes per SF-36 Subscale From Baseline to End of Study
Determinants of Relevant Standardized Regression
SF-36 Subscale QoL Changes Coefficient (95% CI) p Value
Relevant Improvement
Physical functioning Sinus rhythm at study end 0.15 (0.04 to 0.27) 0.007
Role physical Sinus rhythm at study end 0.12 (0.00 to 0.24) 0.047
Complaints of AF at baseline 0.12 (0.01 to 0.24) 0.041
Bodily pain Duration of present AF ⬍32 days* ⫺0.13 (⫺0.24 to ⫺0.02) 0.024
Social functioning Duration of present AF ⬍32 days* ⫺0.12 (⫺0.23 to ⫺0.10) 0.032
Age ⬍69 years* ⫺0.18 (⫺0.29 to ⫺0.07) 0.001
Vitality Sinus rhythm at study end 0.23 (0.11 to 0.33) ⬍ 0.001

Relevant Decrease

Role emotional Coronary artery disease at baseline ⫺0.20 (⫺0.32 to ⫺0.08) 0.001
Vitality Diabetes at baseline ⫺0.14 (⫺0.26 to ⫺0.03) 0.011
*Median value. No significance was reached on multivariate analysis in the subscales of general health and mental health.
AF ⫽ atrial fibrillation; CI ⫽ confidence interval; QoL ⫽ quality of life; SF-36 ⫽ Medical Outcomes Study Short-Form 36.
246 Hagens et al. JACC Vol. 43, No. 2, 2004
Quality of Life in AF January 21, 2004:241–7

health scores of QoL. It may be speculated that these showed that after three months of rhythm control therapy,
complaints were (predominantly) caused by the presence of QoL improved independent of the drug used, compared
underlying heart disease, and not by AF, especially since with baseline QoL. At 12-month follow-up, QoL remained
fatigue and dyspnea, and not palpitations, were the most unchanged.
frequent complaints in patients with reduced QoL. How- Predictors of changes of QoL. As in CTAF, we also
ever, complaints such as fatigue are also a common finding found that SR at the end of the study was the most
in patients with AF without underlying heart disease (14). important determinant of QoL improvement. In CTAF
Why females had an impaired QoL is difficult to explain. and in the present study, improvements were present for
However, in the Canadian Trial of Atrial Fibrillation both physical and mental health scales, indicating that SR
(CTAF), QoL was also significantly impaired in women may improve exercise tolerance and a sense of vitality. Thus,
compared with men, despite comparable severity of under- rhythm control may be beneficial in improving QoL if
lying heart disease (15). effective. Therefore, better means of maintaining SR may
Rate versus rhythm control. At the end of the study, no have a major general impact on QoL in patients with
differences between the rate and rhythm control groups were persistent AF.
present. For the rate control group, improvements in phys- In the present study, 10% of the patients showed a major
ical and mental scales of the SF-36 were present at 12- QoL improvement, defined as a relevant increase on five or
month follow-up and at the end of the study. Because more SF-36 subscales. Improvements may be expected in
almost all patients had persistent AF, and no spontaneous younger patients, patients with a short duration of AF, and
improvements might be expected given the age of the subjects in whom SR was restored. In general, if SR can be
patients, these may be regarded as a general treatment effect restored and maintained during long-term follow-up, an
of both the arrhythmia and underlying disease. The latter improvement of QoL can be expected. Therefore, these
includes adjustments of rate control therapy and therapy for patients remain candidates for the rhythm control strategy,
the underlying heart disease, as needed, and careful and notwithstanding the results of PIAF, AFFIRM, and RACE
close monitoring by the treating physician and study nurses. (1,6,16).
At study end, physical functioning was significantly re- Study limitations. It is important to state that QoL covers
duced. This is likely related to an impaired physical capacity a wide range of patients’ sense of well-being, complaints in
as a consequence of progression of chronic underlying heart daily living, complaints of cardiac and noncardiac diseases,
disease and noncardiac illness in this elderly study popula- and social functioning. Although the SF-36 is a validated
tion. After 12-month of follow-up, QoL in patients treated questionnaire for QoL research, it is possible that some
according to the rhythm control protocol improved on three aspects of QoL or changes in QoL in patients with AF are
SF-36 subscales but returned to baseline scores at study end. not measured. In further research, additional QoL measure-
This also may relate to the aforementioned issues, but also ments, using, for example, AF-specific questionnaires, as
to the fact that after 12 months, 55% of patients were still previously used by Dorian et al. (5,10), are warranted.
in SR (vs. 39% at study end). Conclusions. Patients with persistent AF have a lower
These trends in both groups indicate that treatment of QoL than do healthy, age-matched controls. This holds
AF in a study like this, with relatively frequent visits, may true especially for patients with complaints of AF, those
improve QoL in the short term, possibly due to treatment with symptoms of HF, and females. Treatment strategy
effects, irrespective of the kind of therapy. However, during (rate or rhythm control) does not greatly influence QoL, as
long-term follow-up, these improvements largely vanish. only minor changes occurred on the SF-36 scores. This
No significant changes in QoL could be demonstrated predominantly relates to the fact that more than half of the
between the two treatment groups. This may relate to the patients in the rhythm control strategy had permanent AF
fact that SR could be maintained only in a minority of
during the last period of follow-up. Improvement of QoL is
patients during long-term follow-up.
most likely to occur in patients in whom SR can be
The CTAF, PIAF, and Atrial Fibrillation Follow-up
maintained during long-term follow-up.
Investigation of Rhythm Management (AFFIRM) investi-
Although rate control is not inferior to rhythm control,
gators recently performed comparable QoL assessments
with regard to morbidity and mortality (AFFIRM and
with follow-up studies at one year (5,6,16). In AFFIRM, no
RACE), long-term SR by a rhythm control approach may
significant differences between the two groups at any point
be preferable for improvement of subjective general
during follow-up could be demonstrated (16). The PIAF
well-being.
investigators showed a significant improvement in QoL at
12-month follow-up for almost all SF-36 subscales in both
the rate and rhythm control groups. In contrast, our study Acknowledgment
showed only a few changes after 12-month follow-up. The We are indebted to Tsjerk Kingma, MSc, of the Trial
CTAF study, which randomized patients after successful Coordination Center, Groningen, the Netherlands, for help
cardioversion to amiodarone, sotalol, or propafenone, with conduction of the study and collection of the data.
JACC Vol. 43, No. 2, 2004 Hagens et al. 247
January 21, 2004:241–7 Quality of Life in AF

8. Aaronson NK, Muller M, Cohen PD, et al. Translation, validation,

Reprint requests and correspondence: Dr. Isabelle C. Van and norming of the Dutch language version of the SF-36 Health
Gelder, Department of Cardiology, Thoraxcenter, University Survey in community and chronic disease populations. J Clin Epide-
Hospital Groningen, P.O. Box 30.001, 9700 RB Groningen, The miol 1998;51:1055–68.
Netherlands. E-mail: [email protected]. 9. Cohen J. Statistical Power Analysis for the Behavioral Sciences,
Revised Edition. New York, NY: Academic Press, 1977:48.
10. Dorian P, Jung W, Newman D, et al. The impairment of health-
REFERENCES related quality of life in patients with intermittent atrial fibrillation:
1. Van Gelder IC, Hagens VE, Bosker HA, et al. A comparison of rate implications for the assessment of investigational therapy. J Am Coll
control and rhythm control in patients with recurrent persistent atrial Cardiol 2000;36:1303–9.
fibrillation. N Engl J Med 2002;347:1834 –40. 11. Howes CJ, Reid MC, Brandt C, et al. Exercise tolerance and quality
2. Bubien RS, Knotts-Dolson SM, Plumb VJ, Kay GN. Effect of of life in elderly patients with chronic atrial fibrillation. J Cardiovasc
radiofrequency catheter ablation on health-related quality of life and Pharmacol Ther 2001;6:23–9.
activities of daily living in patients with recurrent arrhythmias. Circu- 12. Juenger J, Schellberg D, Kraemer S, et al. Health related quality of life
lation 1996;94:1585–91. in patients with congestive heart failure: comparison with other
3. Fitzpatrick AP, Kourouyan HD, Siu A, et al. Quality of life and chronic diseases and relation to functional variables. Heart 2002;87:
outcomes after radiofrequency His-bundle catheter ablation and per- 235–41.
manent pacemaker implantation: impact of treatment in paroxysmal 13. Hobbs FD, Kenkre JE, Roalfe AK, Davis RC, Hare R, Davies MK.
and established atrial fibrillation. Am Heart J 1996;131:499 –507. Impact of heart failure and left ventricular systolic dysfunction on
4. Kay GN, Bubien RS, Epstein AE, Plumb VJ. Effect of catheter quality of life: a cross-sectional study comparing common chronic
ablation of the atrioventricular junction on quality of life and exercise cardiac and medical disorders and a representative adult population.
tolerance in paroxysmal atrial fibrillation. Am J Cardiol 1988;62: Eur Heart J 2002;23:1867–76.
741–4.
14. Kopecky SL, Gersh BJ, McGoon MD, et al. The natural history of
5. Dorian P, Paquette M, Newman D, et al. Quality of life improves with
lone atrial fibrillation: a population-based study over three decades.
treatment in the Canadian Trial of Atrial Fibrillation. Am Heart J
2002;143:984 –90. N Engl J Med 1987;317:669 –74.
6. Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial 15. Paquette M, Roy D, Talajic M, et al. Role of gender and personality
fibrillation—Pharmacological Intervention in Atrial Fibrillation on quality-of-life impairment in intermittent atrial fibrillation. Am J
(PIAF): a randomised trial. Lancet 2000;356:1789 –94. Cardiol 2000;86:764 –8.
7. Ware JE Jr., Sherbourne CD. The MOS 36-item short-form health 16. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate
survey (SF-36). I. Conceptual framework and item selection. Med control and rhythm control in patients with atrial fibrillation. N Engl
Care 1992;30:473–83. J Med 2002;347:1825–33.