Systematic, early rhythm control beneficial for atrial fibrillation patients with or without symptoms: EAST-AFNET 4 trial
Germany: Results from a prespecified analysis of the EAST-AFNET 4 trial showed that the clinical benefit of early, systematic rhythm control were equivalent between asymptomatic and symptomatic patients in the trial. Findings of the study, published in the European Heart Journal, call for a shared decision debating of the benefits of rhythm control therapy in patients with recently diagnosed atrial fibrillation (AF) and a concomitant heart condition.
Recent clinical practice guidelines have recommended rhythm control therapy only for patients with symptomatic AF. The EAST-AFNET 4 trial had showed that early, systematic rhythm control improves clinical outcomes compared to symptom-directed rhythm control. In the prespecified EAST-AFNET 4 analysis, Paulus Kirchhof, Atrial Fibrillation Network (AFNET), Münster, Germany, and colleagues compared the effect of early rhythm control therapy in asymptomatic patients (EHRA score I) to symptomatic patients.
Primary outcome was a composite of death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome, analyzed in a time-to-event analysis.
The research yielded the following findings:
- At baseline, 801/2633 (30.4%) patients were asymptomatic [mean age 71.3 years, 37.5% women, mean CHA2DS2-VASc score 3.4, 169/801 (21.1%) heart failure].
- Asymptomatic patients randomized to early rhythm control (395/801) received similar rhythm control therapies compared to symptomatic patients [e.g. AF ablation at 24 months: 75/395 (19.0%) in asymptomatic; 176/910 (19.3%) symptomatic patients].
- Anticoagulation and treatment of concomitant cardiovascular conditions was not different between symptomatic and asymptomatic patients.
- The primary outcome occurred in 79/395 asymptomatic patients randomized to early rhythm control and in 97/406 patients randomized to usual care (hazard ratio 0.76), almost identical to symptomatic patients.
- At 24 months follow-up, change in symptom status was not different between randomized groups.
"The clinical benefit of early, systematic rhythm control was not different between asymptomatic and symptomatic patients in EAST-AFNET 4," wrote the authors.
"These results call for a shared decision discussing the benefits of rhythm control therapy in all patients with recently diagnosed AF and concomitant cardiovascular conditions," they concluded.
Reference:
Stephan Willems, Katrin Borof, Axel Brandes, Günter Breithardt, A John Camm, Harry J G M Crijns, Lars Eckardt, Nele Gessler, Andreas Goette, Laurent M Haegeli, Hein Heidbuchel, Josef Kautzner, G André Ng, Renate B Schnabel, Anna Suling, Lukasz Szumowski, Sakis Themistoclakis, Panos Vardas, Isabelle C van Gelder, Karl Wegscheider, Paulus Kirchhof, Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial, European Heart Journal, 2021;, ehab593, https://doi.org/10.1093/eurheartj/ehab593
