Abstract
AimsTreatment patterns were compared between randomized groups in EAST-AFNET 4 to assess whether differences in anticoagulation, therapy of concomitant diseases, or intensity of care can explain the clinical benefit achieved with early rhythm control in EAST-AFNET 4.Methods and resultsCardiovascular treatment patterns and number of visits were compared between randomized groups in EAST-AFNET 4. Oral anticoagulation was used in >90% of patients during follow-up without differences between randomized groups. There were no differences in treatment of concomitant conditions between groups. The type of rhythm control varied by country and centre. Over time, antiarrhythmic drugs were given to 1171/1395 (84%) patients in early therapy, and to 202/1394 (14%) in usual care. Atrial fibrillation (AF) ablation was performed in 340/1395 (24%) patients randomized to early therapy, and in 168/1394 (12%) patients randomized to usual care. 97% of rhythm control therapies were within class I and class III recommendations of AF guidelines. Patients randomized to early therapy transmitted 297 166 telemetric electrocardiograms (ECGs) to a core lab. In total, 97 978 abnormal ECGs were sent to study sites. The resulting difference between study visits was low (0.06 visits/patient/year), with slightly more visits in early therapy (usual care 0.39 visits/patient/year; early rhythm control 0.45 visits/patient/year, P < 0.001), mainly due to visits for symptomatic AF recurrences or recurrent AF on telemetric ECGs.ConclusionThe clinical benefit of early, systematic rhythm control therapy was achieved using variable treatment patterns of antiarrhythmic drugs and AF ablation, applied within guideline recommendations.
Highlights
Optimal management of patients with atrial fibrillation (AF) includes anticoagulation, rate control therapy, and therapy of concomitant cardiovascular conditions, which may be supplemented by rhythm control therapy in patients who remain symptomatic on optimal rate control according to current guidelines.[1,2]
Patients with AF remain at high risk of cardiovascular death (1–2%/ year),[3,4,5,6] worsening of heart failure (3.5% of patients hospitalized for heart failure/year4,5,7), and stroke despite appropriate anticoagulation (1%/year8)
Over half of the sites participating in EAST were smaller sites without on-site ablation facilities who cooperated with ablation centres
Summary
Optimal management of patients with atrial fibrillation (AF) includes anticoagulation, rate control therapy, and therapy of concomitant cardiovascular conditions, which may be supplemented by rhythm control therapy in patients who remain symptomatic on optimal rate control according to current guidelines.[1,2] Even on optimal therapy, patients with AF remain at high risk of cardiovascular death (1–2%/ year),[3,4,5,6] worsening of heart failure (3.5% of patients hospitalized for heart failure/year4,5,7), and stroke despite appropriate anticoagulation (1%/year[8]). The EAST-AFNET 4 trial demonstrated that systematic, early initiation of rhythm control therapy results in a 21% relative risk reduction in a composite of cardiovascular death, stroke, and hospitalization for heart failure or acute coronary syndrome in a population of patients with recently diagnosed AF and concomitant cardiovascular conditions.[9,10] The clinical benefit was achieved with equal overall safety, including fewer strokes, numerically lower mortality and more serious adverse events related to rhythm control therapy in patients randomized to early rhythm control. Unintended differences in the delivery of other components of AF therapy such as anticoagulation, therapy of concomitant cardiovascular conditions, or more intensive contacts with the study sites could have influenced the outcome of the study
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