Early rhythm control improves cardiovascular outcomes

The early practice of rhythm control reduces cardiovascular outcomes in patients with early atrial fibrillation and comorbid cardiovascular conditions compared to current evidence-based standard care.

Early control shows advantages over evidence-based standard care

Early initiation of rhythm control reduces cardiovascular outcomes in patients with early atrial fibrillation and comorbid cardiovascular conditions compared to current evidence-based standard care.1 This was the conclusion reached by a research team led by Prof. Paulus Kirchhof of the UKE Hamburg (Universitätsklinikum Hamburg-Eppendorf).

Although early rhythm control was associated with more adverse events, the overall safety of both strategies was comparable and had no effect on the number of hospital overnight stays per year. These results from the EAST-AFNET 4 study were published simultaneously in the New England Journal of Medicine2

Prof. Kirchhof's research team points out that even with the current guideline-based treatment, about 5% of patients with atrial fibrillation experience acute coronary syndrome, heart failure, stroke, or cardiovascular death each year2. The risk of cardiovascular complications is particularly high in the first year after the diagnosis of atrial fibrillation. The effectiveness of rhythm control therapy can increase if it is started early. 

In the EAST-AFNET 4 study presented by Prof. Kirchhof, 2,789 patients with early atrial fibrillation (median time since diagnosis: 36 days) and cardiovascular disease were enrolled who randomly received either early rhythm control therapy or the usual care. Early rhythm control included treatment with antiarrhythmics or catheter ablation after randomization. The usual care, on the other hand, limited rhythm control to the treatment of atrial fibrillation-related symptoms. The first primary endpoint consisted of "death from cardiovascular causes", "stroke" or "hospitalization with worsening heart failure or acute coronary syndrome".

Improving care for patients with early atrial fibrillation

After a median follow-up of 5.1 years, the study was terminated prematurely at the third interim analysis because of its efficacy. 249 patients assigned to early rhythm control (3.9 per 100 person-years) and 316 patients assigned to standard care (5.0 per 100 person-years) experienced an event of the first primary endpoint (HR 0.79; P=0.005). 

The EAST-AFNET 4 study showed that early rhythm control therapy in patients with early atrial fibrillation and cardiovascular disease was associated with a lower risk of cardiovascular outcomes than standard care. The research team believes that these results have the potential to be incorporated into the future application of rhythm control therapy and further improve the care of patients with early atrial fibrillation.

1. Cemetery P. EAST - AFNET 4: Effects of Early Rhythm Control Therapy in Patients with Atrial Fibrillation. Hot Line 1, ESC Congress 2020, 29 Aug.
2. Kirchhof P, et al. Patients with Atrial Fibrillation. New Engl J Med. 2020, August 29 DOI: 10.1056/NEJMoa2019422.

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