Eligibility for early rhythm control in patients with atrial fibrillation in the UK Biobank

Abstract

ObjectiveThe Early Treatment of Atrial Fibrillation for Stroke Prevention (EAST-AFNET4) trial showed a clinical benefit of early rhythm-control therapy in patients with recently diagnosed atrial fibrillation (AF). The generalisability of the results in the general population is not known.MethodsParticipants in the population-based UK Biobank were assessed for eligibility based on the EAST-AFNET4 inclusion/exclusion criteria. Treatment of all eligible participants was classified as early rhythm-control (antiarrhythmic drug therapy or AF ablation) or usual care. To assess treatment effects, primary care data and Hospital Episode Statistics were merged with UK Biobank data.Efficacy and safety outcomes were compared between groups in the entire cohort and in a propensity-matched data set.ResultsAF was present in 35 526/502 493 (7.1%) participants, including 8340 (988 with AF <1 year) with AF at enrolment and 27 186 with incident AF during follow-up. Most participants (22 003/27 186; 80.9%) with incident AF were eligible for early rhythm-control.Eligible participants were older (70 years vs 63 years) and more likely to be female (42% vs 21%) compared with ineligible patients. Of 9004 participants with full primary care data, 874 (9.02%) received early rhythm-control. Safety outcomes were not different between patients receiving early rhythm-control and controls. The primary outcome of EAST-AFNET 4, a composite of cardiovascular death, stroke/transient ischaemic attack and hospitalisation for heart failure or acute coronary syndrome occurred less often in participants receiving early rhythm-control compared with controls in the entire cohort (HR 0.82, 95% CI 0.71 to 0.94, p=0.005). In the propensity-score matched analysis, early rhythm-control did not significantly decrease of the primary outcome compared with usual care (HR 0.87, 95% CI 0.72 to 1.04, p=0.124).ConclusionAround 80% of participants diagnosed with AF in the UK population are eligible for early rhythm-control. Early rhythm-control therapy was safe in routine care.

Attaining sinus rhythm mediates improved outcome with early rhythm control therapy of atrial fibrillation: the EAST-AFNET 4 trial

“…The safety of ERC has been replicated in several analyses of large record data sets in South Korea, 17 the USA, 5 and in the UK BioBank. 6 Consistent with our observation, randomization to the antiarrhythmic drug dronedarone was associated with reduced cardiovascular mortality and less ischaemic strokes (HR 0.66; 95% CI 0.45–0.96) in a subanalysis of the ATHENA trial (a placebo-controlled, double-blind, parallel arm trial to assess the efficacy of dronedarone 400 mg twice daily for the prevention of cardiovascular hospitalization or death from any cause in patients with AF/atrial flutter), 18 in addition to reducing a primary outcome of death or cardiovascular hospitalization. 19 Even the lack of effectiveness of dronedarone in the subsequent PALLAS study, where dronedarone therapy without restoration of sinus rhythm was associated with worse cardiovascular outcomes, can be aligned with our analysis.…”

“… 5 , 6 Based on the inclusion criteria of the EAST-AFNET 4 trial, the majority of patients with new-onset AF are eligible for ERC. 6 The results have started to shift the use of rhythm control therapy from a symptom-driven therapy to a risk-reducing strategy aiming at restoring and maintaining sinus rhythm as the default therapy in patients with recently diagnosed AF and stroke risk factors. 7 , 8 …”

Early Diagnosis of Atrial Fibrillation and Stroke Incidence in Primary Care: Translating Measurements into Actions—A Retrospective Cohort Study

“…The application of a clinical risk model ( Figure S1 ) could optimize the selection of candidates for screening even further, and early anticoagulation and early treatments such as cryoablation or drug therapy [ 67 ] may modify the chronic progression of atrial fibrillation, lowering stroke risk rates. Around 80% of the participants diagnosed with AF in the United Kingdom population are eligible for early cardiac rhythm control [ 68 ], and the implementation of new digitalhealth technologieshas the potential to improve outcomes by facilitating self-management and by enabling earlier detection and intervention for adverse events [ 69 , 70 , 71 ]. Finally, the use of artificial intelligence (AI) approaches in stroke risk prediction showed a significant ability to predict the risk of stroke occurrence, but it did not significantly improve discriminative accuracy for new-onset stroke compared with pooled cohort equations [ 72 ].…”

Effectiveness of early rhythm control in improving clinical outcomes in patients with atrial fibrillation: a systematic review and meta-analysis

“…No additional studies were found in the reference lists of previous reviews [17,18]. Finally, a total of 8 studies [8,[10][11][12][19][20][21][22] (1 RCT [8], 2 post hoc analyses of RCTs [11,12], and 5 observational cohorts [10,[19][20][21][22]) were included in this meta-analysis.…”

“…In addition, the modest number of included studies limited the application of other techniques to tease out potential contributors (e.g., meta-regression based on population age, study period). Second, we did not consider safety outcomes because only two included studies (Kirchhof et al and Kany et al) [8,20] fully presented serious adverse events, suggesting that the safety outcomes did not differ between early rhythm-control therapy and usual care. In addition, the quality of life was not considered in our study because it was assessed as outcome in two included studies (Kirchhof et al and Proietti et al).…”