Thread: To me, the most stunning report from #ESCCongress thus far: RATE-AF trial
Older pts w/ permanent AF + shortness of breath. (there are lots of these pts).
Rate control is crucial
In 2020, most receive beta-blockers.
But BB can cause dyspnea.
What about dig?
Gulp! 1/

Rate-AF randomized these pts to bb vs digoxin. Here is the protocol paper: https://bmjopen.bmj.com/content/bmjopen/7/7/e015099.full.pdf
Crucially they looked at quality of life. That's a really important outcome.

The results shocked me. Look at heart rates. Dig isn't supposed to be this good.

Here are the money slides. Short story: better quality and of life and even bnp on dig vs BB

Given the oodles of (flawed) observational data suggesting dig worsens outcomes, the authors looked at clinical events. These are not powered formally, but look... again, better with digoxin.

The authors conclude that dig be moved to first line. This is a nice study but that may be a bit of big leap. That said, at minimum, this evidence takes dig out of the poison category. We ought to have a confirmatory trial.

I have written on the weakness of the data that relegated dig to the 'avoid' category. The RCT level evidence for the drug is neutral. Observational data is flawed by indication bias. https://www.medscape.com/viewarticle/916033

Finally, dig needs to be used carefully. Which you can do in a trial but harder in real world. This is an Imp point for external validity.
@theheartorg @escardio @DrAfzalSohaib @DRTomlinsonEP @majazayeri @Moscoso_Costa
@nmsdegroot @Dominik_Linz @sgjeffrey

Oh, I forgot the link to the presentation https://esc2020.escardio.org/detail/videos/arrhythmias-and-device-therapy/video/6185099441001/rate-af:-rate-control-therapy-evaluation-in-permanent-atrial-fibrillation?autoStart=true