"Early Rhythm-Control Therapy in Patients with Atrial Fibrillation". The New England Journal of Medicine. Published on August 29, 2020. Updated on October 13, 2020.
Links to original sources: Wiki Journal Post Full Journal Article
Does early rhythm-control therapy improve outcomes over usual care in patients with early atrial fibrillation (AF) and cardiovascular (CV) conditions?
Early rhythm-control therapy in patients with atrial fibrillation diagnosed ≤1 year before and with cardiovascular conditions reduced the risk of adverse cardiovascular outcomes compared to usual care, without significantly affecting the number of nights spent in the hospital.
Previous trials did not show the superiority of rhythm control over rate control in patients with established atrial fibrillation. The Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) investigated whether an early rhythm-control strategy that includes ablation would improve outcomes compared to usual care in patients with early-onset AF and additional CV conditions.
Modern guidelines do not specify the timing of rhythm vs. rate control initiation in the management of AF patients.
- International, investigator-initiated, parallel-group, randomized, open, blinded-outcome-assessment trial - N=2,789 patients with recent AF (median time since diagnosis, 36 days) and CV conditions - Interventions: Early rhythm control vs. usual care - Setting: 135 centers across 11 European countries - Enrollment: 2011-2016 - Follow-up: Median 5.1 years per patient - Analysis: Intention-to-treat - Primary outcomes: Death from CV causes, stroke, hospitalization for worsening heart failure or acute coronary syndrome. Secondary outcomes included the number of nights in the hospital per year.
Inclusion Criteria: - Adults (≥18 years) with AF diagnosed ≤12 months before enrollment - Patients also had either age >75 years, prior transient ischemic attack or stroke, or two additional risk factors (e.g., age >65 years, female sex, CHF, etc.)
Exclusion Criteria: - Not specified in the summary
Baseline Characteristics: - Mean age: 70 years, 46% female, median time since AF diagnosis 36 days
- Early rhythm control: Treatment with antiarrhythmic drugs or AF ablation; cardioversion for persistent AF initiated after randomization - Usual care: Rate-control therapy; rhythm control for AF-related symptom management
- First primary outcome event occurred less frequently in early rhythm control than usual care (hazard ratio, 0.79; 96% CI, 0.66 to 0.94; P=0.005) - The number of nights in the hospital was not significantly different (P=0.23)
- Open trial design, which may introduce bias despite blinded outcome assessment - Not designed to assess specific components of rhythm-control therapy - Results may not generalize to patients with later initiation of rhythm-control therapy
Supported by various institutions including the German Ministry of Education and Research, German Center for Cardiovascular Research, and European Heart Rhythm Association, among others.
Kirchhof, P., Camm, A.J., Goette, A., et al. 2020. "Early Rhythm-Control Therapy in Patients with Atrial Fibrillation." NEJM.org.