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Early Rhythm Control for A-fib | EAST-AFNET 4 Trial

October 28, 2020

Written by Meghan Breed

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Early rhythm control of atrial fibrillation was associated with a lower risk of cardiovascular outcomes, including cardiovascular-related death as well as stroke and hospitalization for worsening heart failure or acute coronary syndrome.

Why does this matter?
Patients with atrial fibrillation are diagnosed with stroke, ACS, CHF or cardiovascular-related deaths at a rate of 5% per year.  The risk of cardiovascular complications seems to be highest during the first year following diagnosis, a period referred to “early atrial fibrillation.”  Would early rhythm control reduce this risk?

I can no longer AFFIRM prior studies…
Patients diagnosed with atrial fibrillation within the past 12 months were randomized to receive either usual care or rhythm control therapy; all patients received treatment of cardiovascular conditions, anticoagulation and rate control.  Patients assigned to the rhythm control arm received a combination of pharmacotherapy, cardioversion or ablation.  Flecainide was the most commonly use anti-arrhythmic (35.9%) followed by amiodarone (19.6%).  The first primary outcome was a composite of death from cardiovascular causes, stroke, or hospitalization with worsening CHF or ACS. The first primary outcome occurred in 249 patients (3.9 per 100 person-years) in the rhythm control group and 316 patients (5.0 per 100 person-years) in the usual care group resulting in an absolute difference in risk of 1.1 events per 100 person-years.  Interestingly, this study included a secondary primary outcome that looked at the number of nights spent in the hospital per year, which did not differ among the treatment groups.  Patients assigned to the treatment arm had a higher incidence of adverse events related to drug toxicity and ablation (pericardial tamponade and bleeding, known complications of this procedure).  Prior studies showed no advantage of rhythm control, most notably, the AFFIRM trial published in 2002.  In contrast to previous studies, this study included ablation as a rhythm control strategy and kept patients in both the usual care group and rhythm control group on anticoagulation throughout the follow-up period.  All patients that were enrolled in this study were deemed eligible for randomization to both the usual care and rhythm control group.  Therefore, this probably excluded patients that were symptomatic and may not be generalizable to the acute care setting.

Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020 Aug 29. doi: 10.1056/NEJMoa2019422. Online ahead of print.

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