Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial. (27th August 2021)

• Record Type: Journal Article
• Authors: Willems, Stephan; Borof, Katrin; Brandes, Axel; Breithardt, Günter; Camm, A John; Crijns, Harry J G M; Eckardt, Lars; Gessler, Nele; Goette, Andreas; Haegeli, Laurent M; Heidbuchel, Hein; Kautzner, Josef; Ng, G André; Schnabel, Renate B; Suling, Anna; Szumowski, Lukasz; Themistoclakis, Sakis; Vardas, Panos; van Gelder, Isabelle C; Wegscheider, Karl; Kirchhof, Paulus
• Is Part Of: European heart journal. Volume 43:Number 12(2022)
• Page Start: 1219
• Page End: 1230
• Publication Date: 2021-08-27
• Subjects: Atrial fibrillation -- Symptoms -- Rhythm control -- Ablation -- Antiarrhythmic drugs -- Clinical trial; Cardiology -- Periodicals; Heart -- Diseases -- Periodicals; 616.12005
• DOI: 10.1093/eurheartj/ehab593
• Languages: English
• ISSNs: 0195-668X

Abstract

Abstract: Aims: Clinical practice guidelines restrict rhythm control therapy to patients with symptomatic atrial fibrillation (AF). The EAST-AFNET 4 trial demonstrated that early, systematic rhythm control improves clinical outcomes compared to symptom-directed rhythm control. Methods and results: This prespecified EAST-AFNET 4 analysis 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. At baseline, 801/2633 (30.4%) patients were asymptomatic [mean age 71.3 years, 37.5% women, mean CHA2 DS2 -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, P = 0.672]. 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, 95% confidence interval [0.6; 1.03]), almost identical to symptomatic patients. At 24 months follow-up, change in symptom status was not different between randomized groups ( P = 0.19). Conclusion: The clinical benefit of early, systematic rhythm control was not different between asymptomatic and symptomatic patients in EAST-AFNET 4. 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 (EAST-AFNET 4; ISRCTN04708680; NCT01288352; EudraCT2010-021258-20). Graphical Abstract: