Real-world applicability and impact of early rhythm control for European patients with atrial fibrillation: a report from the ESC-EHRA EORP-AF Long-Term General Registry

Marco Proietti,Gregory Y H Lip,The Esc-Ehra Eorp-Af Long-Term General Registry Investigators ,Gheorghe-Andrei Dan,Laurent Fauchier,Giuseppe Boriani,Deirdre A Lane,Francisco Marin,Tatjana S Potpara,Marco Vitolo,Stephanie L Harrison,Michael Nabauer

doi:10.1007/s00392-021-01914-y

Abstract

BackgroundUse of rate/rhythm control is essential to control symptoms in patients with atrial fibrillation (AF). Recently, the EAST-AFNET 4 trial described how early rhythm control strategy was associated with a lower risk of adverse clinical outcomes.ObjectivesThe aim was to evaluate the real-world applicability and impact of an early rhythm control strategy in patients with AF.MethodsUse of an early rhythm control strategy was assessed in a European cohort of AF patients derived from the EHRA-ESC EORP-AF General Long-Term Registry. Early rhythm control was defined as use of antiarrhythmic drugs or cardioversion/catheter ablation. The primary outcome included cardiovascular death, stroke, acute coronary syndrome, and worsening of heart failure. Quality of life and health-care resource usage were also assessed as outcomes.ResultsAmong the 10,707 patients evaluated for eligibility to EAST-AFNET 4, a total of 3774 (34.0%) were included. Early rhythm control was associated with better quality of life, but with greater use of health-care resources. During follow-up, the primary outcome occurred less often in early rhythm control patients than in those with no rhythm control (13.6% vs. 18.5%, p < 0.001). In the multivariate adjusted Cox regression model, no significant difference was found between no rhythm control and early rhythm control, for the primary outcome. No difference in the primary outcome between early rhythm control and ‘no rhythm control patients’ adherent to Atrial fibrillation Better Care (ABC) pathway’ was evident (p = 0.753)ConclusionsUse of an early rhythm control strategy was associated with a lower rate of major adverse events, but this difference was non-significant on multivariate analysis, being mediated by differences in baseline characteristics and clinical risk profile. Early rhythm control was associated with a higher use of health-care resources and risk of hospital admission, despite showing better quality of life.Graphic abstract

Highlights

Patient-centred, symptom-directed decisions on rate or rhythm control are pivotal considerations for the clinical management of patients with atrial fibrillation (AF)
Use of an early rhythm control strategy was associated with a lower rate of major adverse events, but this difference was non-significant on multivariate analysis, being mediated by differences in baseline characteristics and clinical risk profile
Rhythm control was associated with a higher use of health-care resources and risk of hospital admission, despite showing better quality of life

Summary

Introduction

Patient-centred, symptom-directed decisions on rate or rhythm control are pivotal considerations for the clinical management of patients with atrial fibrillation (AF) This approach is recommended by the European Society of Cardiology (ESC) 2020 Clinical Guidelines for AF management [1] and is part of the ‘B’ criterion of the Atrial fibrillation Better Care (ABC) pathway for the integrated care management of patients with AF [2]. It has long been debated whether rate vs rhythm control strategy could have differential impact on major clinical outcomes, especially the risk of all-cause death occurrence [3,4,5].

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