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Equal benefits of early rhythm control in AF subtypes

Presented by
Dr Andreas Goette, St. Vincenz Hospital Paderborn, Germany
AHA 2021
In a prespecified analysis of the EAST-AFNET 4 trial, early rhythm control showed similar clinical benefits for patients with first-diagnosed atrial fibrillation (AF), patients with persistent AF, and patients with paroxysmal AF. However, patients with first-diagnosed AF demonstrated higher hospitalisation rates than patients with paroxysmal or persistent AF when they were randomised to early rhythm-control therapy.

The multicentre, investigator-initiated EAST-AFNET 4 trial (NCT01288352) was conducted to assess the benefits of early rhythm-control therapy compared with usual care in patients with early, recently diagnosed AF [1]. Patients with a CHA₂DS₂-VASc score of ≥2 and recent onset (≤1 year) AF were eligible for randomisation. The primary outcome was a composite of cardiovascular death, stroke, heart failure worsening, or acute coronary syndrome. The previously published results displayed clinical benefits of early rhythm control compared with usual care (HR 0.79; P=0.005) [2].

Dr Andreas Goette (St. Vincenz Hospital Paderborn, Germany) presented the prespecified analysis, which divided AF patients into 3 groups: first-diagnosed AF (n=1,048), paroxysmal AF (n=994), and persistent AF (n=743). The same composite outcome was evaluated as the first primary outcome. The second primary outcome was the number of nights spent in hospital.

After 8 years of follow-up, the clinical benefits of early rhythm control were consistent amongst all 3 subgroups (first-diagnosed AF HR 0.91; paroxysmal AF HR 0.67; persistent AF HR 0.76), without significant heterogeneity of effect between groups (P-interaction=0.39). However, the nights spent in hospital in the rhythm-control group were significantly increased in patients with first-diagnosed AF (mean 1.38/year; 95% CI 1.12–1.70) compared with patients with paroxysmal AF (0.84; 95% CI 0.67-1.03) or persistent AF (1.02; 95% CI 0.80-1.30; P-interaction=0004). Additional analysis showed that this effect was mainly driven by events that occurred within the first 10 days after diagnosis (see Figure). Notably, the risk of hospitalisation due to acute coronary syndrome was significantly increased in patients with first-diagnosed AF.

Figure: Subgroup analysis across AF subtypes and time since diagnosis [1]
AF, atrial fibrillation; FDAF, first-diagnosed AF.

Furthermore, the 2-year EQ-5D scores for these subgroups displayed a decreased quality of life in patients with first-diagnosed AF (mean delta -2.16) compared with patients paroxysmal AF (+2.49) and persistent AF (+3.96; P=0.019). Dr Goette argued that the drop in quality of life of those with first-diagnosed AF may be related to the increased rates of hospitalisations or other events in this group. Moreover, he explained that these increased rates suggest that first-diagnosed AF may be a biomarker for concomitant cardiovascular disease; a pattern that could not be observed in patients with chronic types of AF. Careful monitoring of patients with first-diagnosed AF, especially during the first weeks after diagnosis is therefore recommended, according to Dr Goette.

    1. Goette A, et al. Patients with first diagnosed atrial fibrillation are at high risk for cardiovascular events and suitable for early rhythm control: The EAST-AFNET 4 trial. FS05, AHA Scientific Sessions 2021, 13–15 November.
    2. Kirchhof P, et al. N Engl J Med 2020;383:1305–16.


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