Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial

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 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, 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).

Multimorbidity and Polypharmacy in Chinese Emergency Department Patients With Atrial Fibrillation and Impacts on Clinical Outcomes

“…Although these results may be confusing, they underscore the role that multimorbidity may affect the outcomes of rhythm control manage. Recent a prespecified EAST-AFNET 4 analysis compared the effect of early rhythm control therapy in asymptomatic patients (EHRA score I) to symptomatic patients, showed no difference in effectiveness of rhythm control strategy among symptomatic and asymptomatic patients, support the systematic, early initiation of rhythm control therapy in all patients with AF and concomitant cardiovascular conditions in dependent of their AF-related symptoms (27). Another prespecified sub-analysis of the randomized EAST-AFNET4 trial, find out rhythm control therapy conveys clinical benefit when initiated within 1 year of diagnosing AF in patients with signs or symptoms of HF (28).…”

Optimal Rhythm Control Strategy in Patients With Atrial Fibrillation

“… 21) A similar proportion has been observed in other trials and registries, such as the AFFIRM trial and Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) and Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registries. 15) 61) 62) Recently, Willems et al 63) showed that the benefit of early rhythm control was consistently observed regardless of symptom status in the participants of the EAST-AFNET.…”

Rhythmusmanagement bei Vorhofflimmern

“…Die internationalen Leitlinien empfehlen die Einleitung der rhythmuserhaltenden Therapie bei Patienten, die trotz adäquater Herzfrequenzkontrolle weiterhin symptomatisch sind. Eine Subanalyse der EAST-Studie konnte demonstrieren, dass asymptomatische Patienten mit einem EHRA-Stadium-I und kürzlich diagnostiziertem VHF von der Rhythmuskontrolle und damit vom Erhalt des Sinusrhythmus genauso profitieren wie symptomatische Patienten 32 ( Abb. 1 ).…”

“…Subanalyse der EAST-AFNET-4-Studie unter Einbeziehung der symptomatischen und asymptomatischen Patienten. Der klinische Benefit eines prognostischen Vorteils der frühen Rhythmuskontrolle findet sich unabhängig von der Symptomatik bei symptomatischen und asymptomatischen Patienten im Vergleich zur Frequenzkontrolle (nach Daten aus[32]). EAST -AFNET 4 StudiePrimärer Endpunkt: kardiovaskulärer Tod, Schlaganfall oder Hospitalisierung aufgrund einer Verschlechterung der Herzinsuffizienz oder…”