Rheumatic Heart Disease (RHD) often begins with untreated Group A Streptococcal infections leading to acute rheumatic fever and potentially progressing to Mitral Stenosis (MS), a condition characterized by the narrowing of the mitral valve that disrupts normal blood flow and increases atrial pressure. This pathology is closely associated with Atrial Fibrillation (AF), the most common arrhythmia in patients with MS, affecting 30-40% of such patients, with prevalence increasing with age and disease duration. The management of AF in this group focuses on anticoagulation to prevent thromboembolic events and heart rate control through medications like beta-blockers and digitalis to improve symptoms and cardiac efficiency.
Despite the guidance provided by the Rate Control Efficacy in Permanent Atrial Fibrillation (RACE II) trial, which showed non-inferiority of lenient rate control (resting heart rate \<110 bpm) compared to strict control (resting heart rate \<80 bpm) in reducing cardiovascular morbidity and mortality, no studies have specifically explored these strategies in patients with AF and rheumatic MS. This research gap underscores the importance of our study, aiming to assess the safety and efficacy of lenient versus strict rate control in this distinct clinical subset, potentially offering critical insights that could lead to optimized, personalized treatment protocols for these high-risk patients.
The objective of this clinical trial is to evaluate the effectiveness of different heart rate control strategies in improving clinical outcomes for patients with atrial fibrillation associated with rheumatic mitral stenosis. The outcomes of interest include reducing hospitalizations, enhancing quality of life, and improving functional capacities within three months follow-up period. The study compares two heart rate control strategies: strict control, with a target resting heart rate of 60-80 beats per minute (bpm), and lenient control, with a target resting heart rate of 81-110 bpm. The primary research questions are:
* Can lenient versus strict heart rate control reduce rehospitalization in patients with atrial fibrillation and rheumatic mitral stenosis?
* Does lenient versus strict heart rate control improve quality of life in these patients?
* Does lenient versus strict heart rate control enhance their functional capacity?
To determine whether one strategy is non-inferior to the other, researchers will compare strict and lenient rate control outcomes. Participants will:
* Receive standardized pharmacological treatment according to the PERKI (Indonesian Heart Association) guidelines for Atrial Fibrillation, potentially including beta-blockers, digoxin, or a combination thereof. This treatment regimen will be monitored monthly to adjust dosages and achieve the targeted heart rate.
* Once the target heart rate is achieved, participants will undergo bi-weekly telephone follow-ups to monitor for any signs and symptoms.
* Additionally, after reaching the heart rate target, participants will attend monthly follow-up visits at the cardiology outpatient clinic for three consecutive months to assess clinical outcomes, including hospitalization rates, quality of life via the SF-36 questionnaire, and functional capacity using the 6-minute walk test (6MWT).
* Cardiac function will be evaluated through echocardiography at the time of enrollment and at the end of the follow-up period.
The study has been approved by Health Research Ethics Committee from the main hospital (Saiful Anwar Hospital) and the satellite hospitals, i.e. Dr. Iskak Regional General Hospital and Prima Husada Sukorejo Hospital. The participants and the outcome assessors will be blinded to ensure the objectiveness, whereas the care providers would oversee the standardized treatments and heart rate control targets.
