Patients, the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT‐AF) Investigators and

Background Most patients with atrial fibrillation ( AF ) require rate control; however, the optimal target heart rate remains under debate. We aimed to assess rate control and subsequent outcomes among patients with permanent AF . Methods and Results We studied 2812 US outpatients with permanent AF in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation. Resting heart rate was measured longitudinally and used as a time‐dependent covariate in multivariable Cox models of all‐cause and cause‐specific mortality during a median follow‐up of 24 months. At baseline, 7.4% (n=207) had resting heart rate <60 beats per minute (bpm), 62% (n=1755) 60 to 79 bpm, 29% (n=817) 80 to 109 bpm, and 1.2% (n=33) ≥110 bpm. Groups did not differ by age, previous cerebrovascular disease, heart failure status, CHA 2 DS 2 ‐ VAS c scores, renal function, or left ventricular function. There were significant differences in race ( P =0.001), sinus node dysfunction ( P =0.004), and treatment with calcium‐channel blockers ( P =0.006) and anticoagulation ( P =0.009). In analyses of continuous heart rates, lower heart rate ≤65 bpm was associated with higher all‐cause mortality (adjusted hazard ratio [ HR ], 1.15 per 5‐bpm decrease; 95% CI , 1.01 to 1.32; P =0.04). Similarly, increasing heart rate >65 bpm was associated with higher all‐cause mortality (adjusted HR , 1.10 per 5‐bpm increase; 95% CI , 1.05 to 1.15; P <0.0001). This relationship was consistent across endpoints and in a broader sensitivity analysis of permanent and nonpermanent AF patients. Conclusions Among patients with permanent AF , there is a J‐shaped relationship between heart rate and mortality. These data support current guideline recommendations, and clinical trials are warranted to determine optimal rate control. Clinical Trial Registration URL : http://clinicaltrials.gov/ . Unique identifier: NCT01165710.