Early Rhythm Control and the Risks of Ischemic Stroke, Heart Failure, Mortality, and Adverse Events When Performed Early (<3 Months): A Nationwide Cohort Study of Newly Diagnosed Patients with Atrial Fibrillation

Abstract

Background: In EAST-AFNET 4 trial, early rhythm control was associated with better clinical outcomes for patients with atrial fibrillation (AF). However, whether the better outcomes of patients assigned to rhythm control were solely due to “early” intervention or because of more regular and structured follow up was unclear. Objective: To investigate whether the findings of EAST trial are applicable to the ‘real world’ clinical setting, where a less structured management protocol is operated. Methods: From 2001 to 2016, 301,064 newly-diagnosed AF patients were identified from Taiwan National Health Insurance Research Database. Among these patients, 62,649 AF patients receiving antiarrhythmic drugs or catheter ablation within 1 year after AF being diagnosed were categorized as the early rhythm control group, and the remaining 238,415 patients were defined as usual care group. Risk of clinical events were compared. Results: Compared to usual care, early rhythm control was associated with a lower adjusted risk of ischemic stroke(aHR 0.771; p&lt;0.001), heart failure(aHR 0.851; p&lt;0.001), acute myocardial infarction(aHR 0.915; p&lt;0.001), mortality(aHR 0.794; p&lt;0.001) and composite adverse events(aHR 0.823; p&lt;0.001). Compared to usual care, the lower risks of ischemic stroke(aHR 0.746), heart failure(aHR 0.819), mortality(aHR 0.777) and composite adverse events(aHR 0.802) associated with early rhythm control were even more evident when performed early (&lt;3months)(pint&lt;0.001). Principal results were generally consistent for majority of subgroups studied and among the cohort after propensity matching. Conclusions: Early rhythm control, especially when performed earlier (&lt;3months), was associated with a lower risk of adverse events than usual care among patients with early AF.

Thrombosis and Haemostasis 2022 Editors' Choice Papers

“…A nationwide cohort study confirmed that on routine daily care, early rhythm control was associated with lower risks of ischemic stroke, heart failure, mortality, and composite adverse events compared with usual care. 25 Interestingly, when early rhythm control was performed earlier (i.e., within the first 3 months after AF diagnosis), the risk of clinical events was lower, and aligned with other studies showing better outcomes in younger patients, with less comorbidities. 26 Combined with opportunistic single time-point screening electrocardiogram, the diagnosis and management of AF could be significantly improved, thereby reducing ischemic stroke rate.…”

Risk of Ischemic Bowel Disease in Patients With Atrial Fibrillation Receiving Warfarin or Non-vitamin K Antagonist Oral Anticoagulants

“…Patients' original identification numbers have been encrypted in this cohort dataset to protect privacy, but the encrypting procedure was consistent so that a linkage of the claims belonging to the same patient was feasible within the NHI database and can be followed continuously. Details about Taiwan NHIRD have been provided in our previous studies (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20), and the accuracy of the NHIRD has been validated (21,22).…”

Early rhythm control vs. rate control in atrial fibrillation: A systematic review and meta-analysis

“…Six studies assessed ischemic stroke (10,11,(13)(14)(15)17). Early rhythm control was linked to a lower risk of stroke in the patients (RR, 0.77; 95% CI 0.67-0.87; P < 0.0010; I 2 = 64%; Figure 3).…”

“…However, the treatment of AF has changed dramatically since the above RCTs were published. Several studies have recently shown that the incidence of adverse cardiovascular outcomes was reduced by early rhythm control compared with rate control (10)(11)(12)(13)(14)(15)(16)(17). To determine whether early rhythm control is better than rate control in patients with AF, we performed a systematic review and metaanalysis.…”