• Deborah A Marshall, Adrian R Levy, Humberto Vidaillet, Elisabeth Fenwick, April Slee, Gordon Blackhouse, H Leon Greene, D George Wyse, Graham Nichol, Bernie J O'Brien, and AFFIRM and CORE Investigators.
• Center for Evaluation of Medicine, McMaster University and St. Joseph's Hospital, Hamilton, Ontario, Canada. marshd@mcmaster.ca
• Ann. Intern. Med. 2004 Nov 2;141(9):653-61.

BackgroundAtrial fibrillation is the most common type of sustained cardiac arrhythmia, but recent trials have identified no clear advantage of rhythm control over rate control. Consequently, economic factors often play a role in guiding treatment selection.ObjectiveTo estimate the cost-effectiveness of rhythm-control versus rate-control strategies for atrial fibrillation in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM).DesignRetrospective economic evaluation. Nonparametric bootstrapping was used to estimate the distribution of incremental costs and effects on the cost-effectiveness plane.Data SourcesData on survival and use of health care resources were obtained for all 4060 AFFIRM participants. Unit costs were estimated from various U.S. databases.Target PopulationPatients with atrial fibrillation who were 65 years of age or who had other risk factors for stroke or death, similar to those enrolled in AFFIRM.Time HorizonMean follow-up of 3.5 years.PerspectiveThird-party payer.InterventionsManagement of patients with atrial fibrillation with antiarrhythmic drugs (rhythm control) compared with drugs that control heart rate (rate control).Outcome MeasuresMean survival, resource use, costs, and cost-effectiveness.Results Of Base Case AnalysisA mean survival gain of 0.08 year (P = 0.10) was observed for rate control. Patients in the rate-control group used fewer resources (hospital days, pacemaker procedures, cardioversions, and short-stay and emergency department visits). Rate control costs 5077 dollars less per person than rhythm control.Results Of Sensitivity AnalysisCost savings ranged from 2189 dollars o 5481 dollars per person. Rhythm control was more costly and less effective than rate control in 95% of the bootstrap replicates over a wide range of cost assumptions.LimitationsResource use was limited to key items collected in AFFIRM, and the results are generalizable only to similar patient populations with atrial fibrillation.ConclusionRate control is a cost-effective approach to the management of atrial fibrillation compared with maintenance of sinus rhythm in patients with atrial fibrillation similar to those enrolled in AFFIRM.

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