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EAST-AFNET 4…RELOADED | Rhythm vs Rate Control for Afib in Low Risk Patients

December 13, 2022

Written by Denrick Cooper

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Rhythm control, compared to rate control, was associated with reduced mortality and cardiovascular risk in low-risk patients with atrial fibrillation.

Why does this matter?
The EAST-AFNET 4 discovered a mortality and stroke benefit to rhythm control; however, the study enrolled an older population with higher stroke risk. This study clarified whether the mortality and cardiovascular benefit of rhythm control was reproducible in healthier, lower-risk populations.

Feel the rhythm! Feel the rhyme!
This retrospective cohort study included 54,216 patients that started either rhythm or rate control treatment within one year of AF diagnosis. The study compared outcomes of treatment mechanism and eligibility for the EAST-AFNET 4 trial (low-risk vs higher-risk population).

In the low-risk (EAST-AFNET 4 ineligible) population, rhythm control was associated with a decrease in the primary composite outcome (cardiovascular death, ischemic stroke, hospitalization for heart failure, or myocardial infarction ): 1.60 vs 2.00 events per 100 person years; HR 0.81 (95%CI 0.66 to 0.98). The eligible group had similar findings: 6.57 vs 7.68 events/100 person years; HR 0.86 (CI 0.81 to 0.92).

Patients in the rhythm control group had fewer hospital days in both study populations: 6.1 vs 8.5 nights per year, low-risk; 25.7 vs 28.5 nights per year, higher-risk. The risk for composite safety outcomes did not differ in either group: 3.59 vs 3.42 events per 100 person-years; HR, 1.05 (CI 0.92 to 1.20), low risk; 9.14 vs 9.22 events per 100 person-years; HR 0.99 (CI 0.94 to 1.05), higher-risk.

Rhythm control treatments could provide more benefits than previously understood. In North America, sometimes the only way to know which treatment a patient will receive depends on which side of the US-Canadian border they are in when they go into Afib. Further research should be done on the most effective and safest options for rhythm control. A paradigm shift may be necessary.

Early Rhythm Control Therapy for Atrial Fibrillation in Low-Risk Patients : A Nationwide Propensity Score-Weighted Study. Ann Intern Med. 2022 Sep 6. doi: 10.7326/M21-4798. Online ahead of print.

What are your thoughts?