In patients with nonvalvular afib, rate control was considered to be no different than rhythm control based on the AFFIRM trial results that was published in 2002. Fast forward 18 years, the EAST-AFNET 4 trial has revisited the question of rhythm control in afib.
The EAST AFNET 4 trial evaluated if early rhythm-control therapy can reduce cardiovascular risk in patients who had recent atrial fibrillation (diagnosed ≤1 year before enrollment).
The trial had significantly positive results in favor of rhythm control. Early rhythm-control therapy was associated with a lower risk of cardiovascular outcomes than usual care among patients with atrial fibrillation and cardiovascular conditions.
Parallel-group, open, blinded-outcome-assessment trial
In total, 2789 patients were included and were randomized to early rhythm
control (N=1395) or usual care (N=1394).
- Recent AF (AF diagnosed within 1 year) and >75 years of age and had a previous TIA or stroke, OR
- Met two of the following criteria: age >65 years, female sex, heart failure (HF), hypertension, diabetes mellitus, severe coronary artery disease, chronic kidney disease, left ventricular hypertrophy (diastolic septal wall width >15 mm)
- CV death, stroke, or hospitalization with heart failure or ACS
3.9% patients in the rhythm control group had primary endpoint event compared to 5% in the usual care group. HR 0.79; 96% CI 0.66 to 0.94; P=0.005
2. Nights spent in hospital/yr
5.8 nights average in rhythm control group compared with 5.1 in usual care. HR 1.08; 99% CI, 0.92 to 1.28; P=0.23
Key Secondary Outcomes:
1. Serious adverse events related to rhythm-control therapy
4.9% patients had a serious adverse event in rhythm control group compared with 1.4% in usual care. HR 1.73; 95% CI, 1.10 to 2.37; P<0.001
Take Home Point:
The usual care mostly included rate controlled and based on the EAST AFNET, rhythm control was noted to be superior in terms of cardiovascular outcomes. Results of this trial are different from other similar trials such as CABANA-AF, AFFIRM, and RACE which is likely due to the fact that patients with recent AF (within 1 year dx) were included.
Ref: Kirchhof et al. N Engl J Med 2020;Aug 29