Early Treatment Of Atrial Fibrillation Research Articles

Invasive strategies for rhythm control of atrial fibrillation: a narrative review.

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia and its increasing prevalence has resulted in a growing healthcare burden. A recent landmark randomized trial, the EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial), highlighted the importance of early rhythm control in AF, which was previously underemphasized. Rhythm control therapy includes antiarrhythmic drugs, direct-current cardioversion, and catheter ablation. Currently, catheter ablation is indicated for patients with AF who are either refractory or intolerant to antiarrhythmic drugs or who exhibit decreased left ventricular systolic function. Catheter ablation can be categorized according to the energy source used, including radiofrequency ablation (RFA), cryoablation, laser ablation, and the recently emerging pulsed field ablation (PFA). Catheter ablation techniques can also be divided into the point-by-point ablation method, which ablates the pulmonary vein (PV) antrum one point at a time, and the single-shot technique, which uses a spherical catheter to ablate the PV antrum in a single application. PFA is known to be applicable to both point-by-point and single-shot techniques and is expected to be promising owing to its tissue specificity, resulting in less collateral damage than catheter ablation involving thermal energy, such as RFA and cryoablation. In this review, we aimed to outline catheter ablation for rhythm control in AF by reviewing previous studies.

Left atrial strain defines functional and structural remodeling in patients with persistent atrial fibrillation

Abstract Background Left atrial (LA) strain is an echocardiographic method to detect atrial dysfunction as a process of structural and functional remodeling of the atria. In patients with persistent atrial fibrillation (AF), functional changes and an enlargement of the LA due to structural remodeling has been described. The aim of our study was 1) the echocardiographic assessment of LA function using LA strain and 2) to investigate the correlation between LA strain and left atrial size index (LAVI) using 3D reconstruction of the LA from multi-detector computed tomography (CT). Methods This study includes patients with persistent AF who underwent LA catheter ablation without prior treatment. All subjects underwent measurement of reservoir (LASr), conduit (LAScd) and contraction (LASct) LA strain using imaging using two-dimensional speckle tracking echocardiography (2D-STE) and cardiac CT. A 3D reconstruction of the LA from the CT was done using EnSite Verismo (Abbott, USA). The LA volume obtained at the end-systole included LA appendage reconstruction and excluded the pulmonary veins. LAVI was calculated by dividing LA volume by body surface area. Results The study included 36 patients (mean age 69 yrs [49 to 80 yrs], 27 male, mean LV-EF 56% [40 to 78%). We found the following LA strain measurement: mean LASr 21% [6 to 52%], mean LAScd -12% [-32 to -0,25%] and mean LASct -9% [-32 to -1%]. LAVI: mean 82 ml/m² [38 to 127 ml/m²]. There is a statistically significant negative correlation between LASr (p = 0.002, r = -0.503) and a statistically positive correlation between LASct (p = 0.003, r = 0.482) compared to the LA volume, whereas there is no statistically significant correlation between LAScd and the LA volume (p = 0.088, r = 0.288). Discussion LA strain in patients with persistent AF as an expression of functional remodeling is reduced compared to normal values in literature. Correlation of LA strain and LAVI are statistically significant for LASr as well as LASct. The correlation between LAScd and LAVI did not reach statistical significance but shows a trend towards a positive correlation. Whether early treatment of AF could prevent further fibrotic remodeling with reducing LA volume and improving LA strain needs further research.

Outcomes of Early Rhythm Control Therapy in Patients With Atrial Fibrillation and a High Comorbidity Burden in Large Real-World Cohorts.

A recent subanalysis of the EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) suggests a stronger benefit of early rhythm control (ERC) in patients with atrial fibrillation and a high comorbidity burden when compared to patients with a lower comorbidity burden. We identified 109 739 patients with newly diagnosed atrial fibrillation in a large United States deidentified administrative claims database (OptumLabs) and 11 625 patients in the population-based UKB (UK Biobank). ERC was defined as atrial fibrillation ablation or antiarrhythmic drug therapy within the first year after atrial fibrillation diagnosis. Patients were classified as (1) ERC and high comorbidity burden (CHA2DS2-VASc score ≥4); (2) ERC and lower comorbidity burden (CHA2DS2-VASc score 2-3); (3) no ERC and high comorbidity burden; and (4) no ERC and lower comorbidity burden. Patients without an elevated comorbidity burden (CHA2DS2-VASc score 0-1) were excluded. Propensity score overlap weighting and cox proportional hazards regression were used to balance patients and compare groups for the primary composite outcome of all-cause mortality, stroke, or hospitalization with the diagnoses heart failure or myocardial infarction as well as for a primary composite safety outcome of death, stroke, and serious adverse events related to ERC. In both cohorts, ERC was associated with a reduced risk for the primary composite outcome in patients with a high comorbidity burden (OptumLabs: hazard ratio, 0.83 [95% CI 0.72-0.95]; P=0.006; UKB: hazard ratio, 0.77 [95% CI, 0.63-0.94]; P=0.009). In patients with a lower comorbidity burden, the difference in outcomes was not significant (OptumLabs: hazard ratio, 0.92 [95% CI, 0.54-1.57]; P=0.767; UKB: hazard ratio, 0.94 [95% CI, 0.83-1.06]; P=0.310). The comorbidity burden interacted with ERC in the UKB (interaction- P=0.027) but not in OptumLabs (interaction-P=0.720). ERC was not associated with an increased risk for the primary safety outcome. ERC is safe and may be more favorable in a population-based sample of patients with high a comorbidity burden (CHA2DS2-VASc score ≥4).

Atrial Fibrillation Detection and Management in Hypertension.

Hypertension is prevalent in >70% of atrial fibrillation patients. In turn, hypertensive patients have up to 73% greater likelihood of atrial fibrillation. Current guidelines recommend that a systematic atrial fibrillation screening may be justified in all patients aged ≥65 years with at least 1 cardiovascular disease, including hypertension. Although most blood pressure monitors include algorithms to detect atrial fibrillation with a high sensitivity of 96 [92-98]% and specificity of 94 [91-96]%, an electrocardiography confirmation is necessary to establish a diagnosis of atrial fibrillation. Early detection and diagnosis of atrial fibrillation is important to allow initiation of atrial fibrillation management. In the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4), hypertension was present in 88% of participants, and early rhythm control therapy lowered the risk of adverse cardiovascular outcomes in patients with early atrial fibrillation aged >75 or with CHA2DS2-VASc score ≥2 (Congestive heart failure, Hypertension, Age ≥75 (doubled), Diabetes, Stroke (doubled), Vascular disease, Age 65-74, Sex category [female]) and cardiovascular condition. Strategies for early atrial fibrillation detection should always be linked to a comprehensive atrial fibrillation work-up infrastructure organized within an integrated ABC pathway (Anticoagulation/Avoid stroke; Better symptom control; Cardiovascular and Comorbidity optimization). For secondary prophylaxis, blood pressure control should be embedded in a combined risk factor management program. In hypertensive patients where no atrial fibrillation is detected, intensive blood pressure lowering therapy for primary prophylaxis should be initiated to reduce the risk of developing atrial fibrillation and other cardiovascular complications in the future. The aim of the article is to review the current literature on atrial fibrillation detection and management in hypertensive patients.

Early Rhythm Control in Patients With Atrial Fibrillation and High Comorbidity Burden.

The randomized EAST-AFNET4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial-Atrial Fibrillation Network) demonstrated that early rhythm control (ERC) reduces adverse cardiovascular outcomes in patients with recently diagnosed atrial fibrillation and stroke risk factors. The effectiveness and safety of ERC in patients with multiple cardiovascular comorbidities is not known. These prespecified subanalyses of EAST-AFNET4 compared the effectiveness and safety of ERC with usual care (UC) stratified into patients with higher (CHA2DS2-VASc score ≥4) and lower comorbidity burden. Sensitivity analyses ignored sex (CHA2DS2-VA score). EAST-AFNET4 randomized 1093 patients with CHA2DS2-VASc score ≥4 (74.8±6.8 years, 61% female) and 1696 with CHA2DS2-VASc score <4 (67.4±8.0 years, 37% female). ERC reduced the composite primary efficacy outcome of cardiovascular death, stroke, or hospitalization for worsening of heart failure or for acute coronary syndrome in patients with CHA2DS2-VASc score ≥4 (ERC, 127/549 patients with events; UC, 183/544 patients with events; hazard ratio [HR], 0.64 [0.51-0.81]; P < 0.001) but not in patients with CHA2DS2-VASc score <4 (ERC, 122/846 patients with events; UC, 133/850 patients with events; HR, 0.93 [0.73-1.19]; P=0.56, Pinteraction=0.037). The primary safety outcome (death, stroke, or serious adverse events of rhythm control therapy) was not different between study groups in patients with CHA2DS2-VASc score ≥4 (ERC, 112/549 patients with events; UC, 132/544 patients with events; HR, 0.84 [0.65, 1.08]; P=0.175), but occurred more often in patients with CHA2DS2-VASc scores <4 randomized to ERC (ERC, 119/846 patients with events; UC, 91/850 patients with events; HR, 1.39 [1.05-1.82]; P=0.019, Pinteraction=0.008). Life-threatening events or death were not different between groups (CHA2DS2-VASc score ≥4, ERC, 84/549 patients with event, UC, 96/544 patients with event; CHA2DS2-VASc scores <4, ERC, 75/846 patients with event, UC, 73/850 patients with event). When female sex was ignored for the creation of higher and lower risk groups (CHA2DS2-VA score), the Pinteraction was not significant for the primary efficacy outcome (P=0.25), but remained significant (P=0.044) for the primary safety outcome. Patients with recently diagnosed atrial fibrillation and CHA2DS2-VASc score ≥4 should be considered for ERC to reduce cardiovascular outcomes, whereas those with fewer comorbidities may have less favorable outcomes with ERC. URL: https://www. gov; Unique identifier: NCT01288352. URL: https://www.clinicaltrialsregister.eu; Unique identifier: 2010-021258-20. URL: https://www.isrctn.com/; Unique identifier: ISRCTN04708680.

Early Rhythm Control Therapy for Atrial Fibrillation in Low-Risk Patients : A Nationwide Propensity Score-Weighted Study.

Rhythm control is associated with lower risk for adverse cardiovascular outcomes compared with usual care among patients recently diagnosed with atrial fibrillation (AF) with a CHA2DS2-VASc score of approximately 2 or greater in EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial). To investigate whether the results can be generalized to patients with low stroke risk. Population-based cohort study. Nationwide claims database of the Korean National Health Insurance Service. 54216 patients with AF having early rhythm control (antiarrhythmic drugs or ablation) or rate control therapy that was initiated within 1 year of the AF diagnosis. The effect of early rhythm control on the primary composite outcome of cardiovascular death, ischemic stroke, hospitalization for heart failure, or myocardial infarction was compared between eligible and ineligible patients for EAST-AFNET 4 (CHA2DS2-VASc score, approximately 0 to 1) using propensity overlap weighting. In total, 37557 study participants (69.3%) were eligible for the trial (median age, 70 years; median CHA2DS2-VASc score, 4), among whom early rhythm control was associated with lower risk for the primary composite outcome than rate control (hazard ratio, 0.86 [95% CI, 0.81 to 0.92]). Among the 16659 low-risk patients (30.7%) who did not meet the inclusion criteria (median age, 54 years; median CHA2DS2-VASc score, 1), early rhythm control was consistently associated with lower risk for the primary outcome (hazard ratio, 0.81 [CI, 0.66 to 0.98]). No significant differences in safety outcomes were found between the rhythm and rate control strategies regardless of trial eligibility. Residual confounding. In routine clinical practice, the beneficial association between early rhythm control and cardiovascular complications was consistent among low-risk patients regardless of trial eligibility. The Ministry of Health and Welfare and the Ministry of Food and Drug Safety, Republic of Korea.

Early Rhythm Control and the Risks of Ischemic Stroke, Heart Failure, Mortality, and Adverse Events When Performed Early (

In the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4), early rhythm control was associated with better clinical outcomes for patients with atrial fibrillation (AF). However, the intervention arm had more structured and regular follow-up, and whether the better outcomes of patients assigned to rhythm control were solely due to "early" intervention or because of more regular and structured follow-up was unclear. In the present study, we aimed to investigate whether the findings of the EAST trial are applicable to the "real-world" clinical setting, where a less structured management protocol is operated. From 2001 to 2016, 301,064 newly diagnosed AF patients were identified from Taiwan National Health Insurance Research Database. Among these patients, 62,649 AF patients receiving antiarrhythmic drugs or catheter ablation within 1 year after AF being diagnosed (similar to the timing definition of the EAST-AFNET 4 trial) were categorized as the early rhythm control group, and the remaining 238,415 patients were defined as usual care group. Risks of clinical events were compared between the two groups. Compared with usual care, early rhythm control was associated with a lower adjusted risk of ischemic stroke (adjusted hazard ratio [aHR]: 0.771, 95% confidence interval [CI]: 0.751-0.792; p < 0.001), heart failure (aHR: 0.851, 95% CI: 0.806-0.899; p < 0.001), acute myocardial infarction (aHR: 0.915, 95% CI: 0.877-0.955; p < 0.001), mortality (aHR: 0.794, 95% CI: 0.782-0.806; p < 0.001), and composite adverse events (aHR: 0.823, 95% CI: 0.813-0.834; p < 0.001). Compared with usual care, the lower risks of ischemic stroke (aHR: 0.746, 95% CI: 0.717-0.775), heart failure (aHR: 0.819, 95% CI: 0.798-0.841), mortality (aHR: 0.777, 95% CI: 0.759-0.795), and composite adverse events (aHR: 0.802, 95% CI: 0.787-0.818) associated with early rhythm control were even more evident when performed early (<3 months) compared to later periods (3-6 months, 7-9 months, and 10-12 months; p int < 0.001). Principal results were generally consistent for majority of subgroups studied and among the cohort after propensity matching. In this nationwide cohort study, early rhythm control therapy was associated with a lower risk of adverse events compared with usual care among patients with early AF. Outcomes were even better with earlier (<3 months) intervention.

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

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...

Presenting Pattern of Atrial Fibrillation and Outcomes of Early Rhythm Control Therapy

BackgroundWhether atrial fibrillation (AF) pattern or timing of AF therapy modifies the effectiveness of early rhythm control (ERC) is not known. ObjectivesThis study sought to compare clinical characteristics and outcomes in patients presenting with different AF patterns on ERC vs usual care. MethodsThe effects of ERC were compared in first-diagnosed AF (FDAF), paroxysmal AF (paroxAF), and persistent AF (persAF) in this prespecified analysis of the EAST-AFNET 4 (Early treatment of atrial fibrillation for stroke prevention) trial. Associations between AF pattern and primary outcomes (first primary outcome: cardiovascular death, stroke, and hospitalization for heart failure and acute coronary syndrome; second primary outcome: nights spent in hospital per year) were compared over a mean follow-up of 5.1 years. Changes in health-related quality of life were assessed by the EQ-5D. ResultsFDAF patients (n = 1,048, enrolled 7 days after diagnosing AF) were slightly older (71 years of age, 48.0% female) than patients with paroxAF (n = 994, 70 years of age, 50.0% female) and persAF (n = 743, 70 years of age, 38.0% female). ERC reduced the primary outcome in all 3 AF patterns. Hospitalizations for acute coronary syndrome were highest in FDAF (incidence rate ratio [IRR]: 1.50; 95% CI: 0.83-2.69; P for interaction = 0.032) compared with paroxAF (IRR: 0.64; 95% CI: 0.32-1.25) and persAF (IRR: 0.50; 95% CI: 0.25-1.00). FDAF patients spent more nights in hospital (IRR: 1.38; 95% CI: 1.12-1.70; P for interaction = 0.004) than paroxAF (IRR: 0.84; 95% CI: 0.67-1.03), and persAF (IRR: 1.02; 95% CI: 0.80-1.30) patients. ERC improved health-related quality of life (EQ-5D score) in patients with paroxAF and persAF but not in patients with FDAF (P = 0.019). ConclusionsERC reduces the first primary composite outcome in all AF patterns. Patients with FDAF are at high risk for hospitalization and acute coronary syndrome, particularly on ERC. (Early treatment of atrial fibrillation for stroke prevention trial; ISRCTN04708680; Early Treatment of Atrial Fibrillation for Stroke Prevention Trial [EAST]; NCT01288352; Early treatment of Atrial fibrillation for Stroke prevention Trial [EAST]; EudraCT2010-021258-20)

The 2020 ESC atrial fibrillation guidelines for atrial fibrillation catheter ablation, CABANA, and EAST.

Prior randomised clinical trials (RCTs) have suggested that rhythm control offers no benefit compared to accepting AF and instituting rate control in terms of all-cause mortality, CV mortality and sudden death; as a consequence, the ESC AF guidelines have recommended rhythm control for reducing AF-related symptoms and improving quality of life. The Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) evaluated whether a more up-to-date rhythm control management strategy provides a benefit in mortality or stroke rates while the Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial evaluated whether catheter ablation was better than drug therapy in preventing a composite of death, disabling stroke, serious bleeding or cardiac arrest. This document critically reviews the recommendations of the 2020 ESC guidelines for the management of AF in the light of these two landmark trials, both of which have underlined the safety of contemporary rhythm control treatment. Considering the safety of the different strategies in modern AF treatment, a personalized approach taking into account the specific patient profile and preferences of the individual patient is needed.

EP News: Allied Professionals

In this prespecified analysis of the multinational randomized Early Treatment of Atrial Fibrillation for Stroke Prevention Trial 4 (EAST-AFNET 4), Willems et al (Eur Heart J August 27, 2021; doi:10.1093/eurheartj/ehab593, PMID 34447995) sought to determine whether early rhythm control therapy improved outcomes as compared with usual care in patients with early atrial fibrillation (AF), regardless of patients’ symptoms at baseline. The trial randomized patients with AF diagnosed within past 12 months who also had age greater than 75 years, a history of stroke or transient ischemic attack, or any 2 of the following criteria—age >65 years, female sex, hypertension, diabetes mellitus, heart failure (HF), coronary artery disease, left ventricular hypertrophy, or chronic kidney disease.

Generalizability of the EAST-AFNET 4 trial: assessing outcomes of early rhythm-control therapy in patients with atrial fibrillation

Abstract Background The Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) demonstrated clinical benefit of early rhythm-control therapy in patients with recently diagnosed atrial fibrillation (AF) and concomitant cardiovascular conditions (CHA2DS2-VASc-Score ≥2) compared to the current practice of limited rhythm-control therapy to improve AF-related symptoms. Purpose To evaluate the generalizability of the EAST-AFNET 4 trial in routine practice, we assessed the proportion of patients who would have met trial eligibility and examined the association between early rhythm-control and clinical outcomes. Methods Using a large US administrative database, we identified 109,739 patients with newly diagnosed AF from July 28th, 2011 to December 30th, 2016, the enrollment period of the EAST-AFNET 4 trial. Eligibility for trial inclusion was assessed based on inclusion criteria. Eligible patients were classified as either receiving early rhythm-control, i.e AF ablation and/or any antiarrhythmic drug therapy, within the first year after AF diagnosis (N=27,106) or patients not receiving early rhythm-control (N=82,633). The date 12 months after the first AF diagnosis was defined as the index date and the start of the follow up period. Propensity score overlap weighting was used to balance patients on 90 baseline characteristics. Cox proportional hazards regression was used to compare early rhythm-control with no early rhythm-control for the primary outcome of a composite end point of all-cause mortality, stroke, or hospitalization with the diagnoses heart failure or myocardial infarction. Results Eligible for the trial were 72.9% (82,633/109,739) of all patients with newly diagnosed AF. Early rhythm-control therapy was associated with a reduction in the composite end point in the overall cohort of patients (hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.75–0.97; P=0.015) with largely consistent treatment effects between patients eligible or ineligible for the trial. The reduction of stroke risk associated with early rhythm-control therapy was found in the overall cohort (HR 0.66; 95% CI 0.47–0.93; P=0.017) and in the trial-eligible cohort (HR 0.67; 95% CI 0.45–0.98; P=0.041). Conclusion In a large health care data set, the majority of patients with newly diagnosed AF were eligible for the trial. Early rhythm-control therapy was associated with a 15% reduction in the composite end point of all-cause mortality, stroke, or hospitalization with the diagnoses heart failure or myocardial infarction, with the greatest benefit in the reduction of stroke risk. The treatment effect was consistent between patients eligible or ineligible for the trial. Patients in routine practice had higher rates of adverse outcomes than the trial, but the relative risk reduction with early rhythm-control therapy was similar. These data demonstrate the potential of early rhythm-control therapy to reduce outcomes in patients with AF. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): German Heart Foundation (Mit Fördermitteln der Deutschen Herzstiftung e.V.)

Early rhythm-control therapy in patients with atrial fibrillation: a nationwide cohort study

Abstract Background In the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4), early rhythm control was associated with better clinical outcomes for patients with atrial fibrillation (AF). However, the intervention arm had more structured and regular followup, and whether the better outcomes of patients assigned to rhythm control were solely due to “early” intervention or because of more regular and structured follow up was unclear. Purpose We aimed to investigate whether the findings of the EAST trial are applicable to the “real world” clinical setting, where a less structured management protocol is operated. Methods From 2001 to 2016, 301,064 newly-diagnosed AF patients were identified from Taiwan National Health Insurance Research Database. Among these patients, 62,649 AF patients receiving antiarrhythmic drugs or catheter ablation within 1 year after AF being diagnosed (similar to the timing definition of the EAST-AFNET 4 trial) were categorized as the early rhythm control group, and the remaining 238,415 patients were defined as usual care group. Risk of clinical events were compared between 2 groups. Results Compared to usual care, early rhythm control was associated with a lower adjusted risk of ischemic stroke (aHR 0.771, 95CI 0.751–0.792; p&amp;lt;0.001), heart failure (aHR 0.851, 95% CI 0.806–0.891; p&amp;lt;0.001), acute myocardial infarction (aHR 0.915, 95% CI 0.877–0.955; p&amp;lt;0.001), mortality (aHR 0.794, 95% CI 0.782–0.806; p&amp;lt;0.001) and composite adverse events (aHR 0.823, 95% CI 0.813–0.834; p&amp;lt;0.001) (Figure). Compared to usual care, the lower risks of ischemic stroke (aHR 0.746, 95% CI 0.717–0.775), heart failure (aHR 0.819, 95% CI 0.798–0.841), mortality (aHR 0.777, 95% CI 0.759–0.795) and composite adverse events (aHR 0.802, 95% CI 0.787–0.818) associated with early rhythm control were even more evident when performed early (&amp;lt;3 months) than later periods (3–6 months, 7–9 months and 10–12 months; pint &amp;lt;0.001). Principal results were generally consistent for majority of subgroups studied and among the cohort after the propensity matching. Conclusions In this nationwide cohort study, early rhythm control therapy was associated with a lower risk of adverse events than usual care among patients with early AF. Outcomes were even better with earlier (&amp;lt;3 months) intervention. Funding Acknowledgement Type of funding sources: None.

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Rillig et al (Circulation July 30, 2021; https://doi.org/10.1161/CIRCULATIONAHA.121.056323, PMID: 34328366) assessed the effect of early rhythm control (ERC) therapy (using antiarrhythmic drugs or catheter ablation) compared to usual care (UC; allowing rhythm control therapy to improve symptoms) on outcomes in prespecified patients with heart failure in the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4 trial). During 5.1-year follow-up, the composite primary outcome of cardiovascular death, stroke, or hospitalization for worsening of heart failure or for acute coronary syndrome occurred less often in patients randomized to ERC therapy (94/396; 5.7 per 100 patient-years) compared with patients randomized to UC (130/402; 7.9 per 100 patient-years) (hazard ratio 0.74; P = .03).

Early Rhythm Control Therapy in Patients With Atrial Fibrillation and Heart Failure.

Even on optimal therapy, many patients with heart failure and atrial fibrillation experience cardiovascular complications. Additional treatments are needed to reduce these events, especially in patients with heart failure and preserved left ventricular ejection fraction. This prespecified subanalysis of the randomized EAST-AFNET4 trial (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) assessed the effect of systematic, early rhythm control therapy (ERC; using antiarrhythmic drugs or catheter ablation) compared with usual care (allowing rhythm control therapy to improve symptoms) on the 2 primary outcomes of the trial and on selected secondary outcomes in patients with heart failure, defined as heart failure symptoms New York Heart Association II to III or left ventricular ejection fraction [LVEF] <50%. This analysis included 798 patients (300 [37.6%] female, median age 71.0 [64.0, 76.0] years, 785 with known LVEF). The majority of patients (n=442) had heart failure and preserved LVEF (LVEF≥50%; mean LVEF 61±6.3%), the others had heart failure with midrange ejection fraction (n=211; LVEF 40%-49%; mean LVEF 44 ± 2.9%) or heart failure with reduced ejection fraction (n=132; LVEF<40%; mean LVEF 31±5.5%). Over the 5.1-year median follow-up, the composite primary outcome of cardiovascular death, stroke, or hospitalization for worsening of heart failure or for acute coronary syndrome occurred less often in patients randomly assigned to ERC (94/396; 5.7 per 100 patient-years) compared with patients randomly assigned to usual care (130/402; 7.9 per 100 patient-years; hazard ratio, 0.74 [0.56-0.97]; P=0.03), not altered by heart failure status (interaction P value=0.63). The primary safety outcome (death, stroke, or serious adverse events related to rhythm control therapy) occurred in 71 of 396 (17.9%) patients with heart failure randomly assigned to ERC and in 87 of 402 (21.6%) patients with heart failure randomly assigned to usual care (hazard ratio, 0.85 [0.62-1.17]; P=0.33). LVEF improved in both groups (LVEF change at 2 years: ERC 5.3±11.6%, usual care 4.9±11.6%, P=0.43). ERC also improved the composite outcome of death or hospitalization for worsening of heart failure. Rhythm control therapy conveys clinical benefit when initiated within 1 year of diagnosing atrial fibrillation in patients with signs or symptoms of heart failure. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01288352. URL: http://www.controlled-trials.com; Unique identifier: ISRCTN04708680. URL: https://www.clinicaltrialsregister.eu; Unique identifier: 2010-021258-20.

The role of timing in treatment of atrial fibrillation: An AFFIRM substudy

In contrast to historical trials, the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) suggests the superiority of early rhythm control over rate control in patients with recent-onset atrial fibrillation (AF). The relative contribution of timing vs improvement in AF therapeutics over time is unclear. This study aimed to isolate the assessment of early intervention for AF from temporal changes in AF treatments through a secondary analysis of subjects from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. We compared rate and rhythm control treatments in AFFIRM subjects stratified by time from their diagnosis of AF. Time-to-event analysis was performed to compare all-cause mortality, cardiovascular hospitalizations, stroke, and number of hospitalization days. Of the 4060 AFFIRM subjects, 2526 subjects (62.2%) had their first episode of AF within 6 months of study enrollment. Participants with "new" AF had a decreased risk of all-cause mortality (P = .001) than did those with prior AF diagnoses. Individuals previously diagnosed with AF were similar in age and demographic characteristics, but had more medical comorbidities, including myocardial infarction (P = .006), diabetes mellitus (P = .002), smoking (P = .003), and hepatic or renal comorbidities (P = .008). There were no differences in mortality, cardiovascular hospitalizations, or stroke between rate and rhythm control strategies in either AF subgroup. AFFIRM subjects diagnosed with AF within 6 months of study enrollment showed no difference in survival, cardiovascular hospitalization, or ischemic stroke between rate and rhythm control strategies. Superiority of rhythm control strategies reported by newer AF trials may be more attributable to the refinement of AF therapies and less related to the timing of intervention.

Management of Atrial Fibrillation in Europe: Current Care Pathways and the Clinical Impact of Antiarrhythmic Drugs and Catheter Ablation

Atrial fibrillation (AF), the most common form of arrhythmia, increases the risk of heart failure, stroke, and death. Management of AF focusses on effectively and safely controlling irregular heart rhythm, improving symptoms, and reducing complications. Early treatment of AF is important as it may improve patient life expectancy and quality of life (QoL). Current European guidelines recommend an integrated approach to AF management that involves shared decision making between patients and multidisciplinary teams of healthcare professionals to improve access to care and patient compliance. Treatment options include the use of anticoagulants, cardioversion, rate control therapies, and rhythm control therapies. Over the long term, rhythm control strategies that include antiarrhythmic drugs (AAD) and catheter ablation are the most common methods for controlling AF. The objective of this review is to highlight current European AF care pathway management recommendations and to examine the clinical, economic, and patient impact of different treatment options, including AAD and catheter ablation. While AAD have been shown to improve QoL and are affordable in the short term, treatment is moderately effective, associated with significant side effects, and can be costly long term. Catheter ablation is a highly effective therapy choice that improves patient wellbeing and is associated with a low rate of ablation-related complications. Compared to drug therapy, catheter ablation provides a significant reduction in AF burden, reduces rates of recurrence, provides a greater improvement in QoL, and facilitates long-term cost savings.

176-20: Cryoballoon ablation as treatment of recent paroxysmal atrial fibrillation. Data from a large cohort of patients followed in a real world multicenter experience

Purpose of the study: Cryoballoon ablation (CBA) has been suggested as first line treatment of patient suffering from lone paroxysmal atrial fibrillation (AF). We evaluated the acute procedural success (APS) and clinical outcome of paroxysmal AF pts comparing those undergoing CBA within 12 months from AF onset (Recent, Group 1) vs. pts undergoing CBA after more than 12 months from AF onset (Not Recent, Group 2). Method Used: From April 2012, 764 patients (70% male, 59 ± 11 years, mean left atrial diameter 41 ± 6 mm) underwent PV cryoablation. Data were collected prospectively in the framework of the One Shot TO Pulmonary vein isolation (1STOP) ClinicalService® project. The main endpoint was AF recurrence after CBA, considering 3 months blanking period. Conclusion: Cryoablation technology is safe and effective as treatment of AF; early treatment of AF seems to reduce AF recurrence compared to patients treated after 12 months from AF history onset.

The EAST study: redefining the role of rhythmcontrol therapy in atrial fibrillation: EAST, the Early treatment of Atrial fibrillation for Stroke prevention Trial.

The EAST study: redefining the role of rhythmcontrol therapy in atrial fibrillation: EAST, the Early treatment of Atrial fibrillation for Stroke prevention Trial.

Improving outcomes in patients with atrial fibrillation: Rationale and design of the Early treatment of Atrial fibrillation for Stroke prevention Trial

Even on optimal therapy including anticoagulation and rate control, major cardiovascular complications (stroke, cardiovascular death, and acute heart failure) are common in patients with atrial fibrillation (AF). Conceptually, maintenance of sinus rhythm could prevent adverse outcomes related to AF. Rhythm control therapy has been only moderately effective in published trials, and its potential benefit was offset by side effects of repeated interventions. Rhythm control therapy applied early after the first diagnosis of AF could preserve atrial structure and function and maintain sinus rhythm more effectively than the current practice of delayed rhythm control (when symptoms persist after otherwise effective rate control). Furthermore, catheter ablation and new antiarrhythmic drugs have enhanced the potential effectiveness and safety of rhythm control therapy. The EAST will test whether an early, modern rhythm control therapy can reduce cardiovascular complications in AF. The EAST (Early treatment of Atrial fibrillation for Stroke prevention Trial) will randomize approximately 3,000 patients with recent onset AF at risk for stroke (CHA₂DS₂VASc score ≥2) to either guideline-mandated usual care or to usual care plus early rhythm control therapy in a prospective, randomized, open, blinded outcome assessment trial. All patients will be followed up until the end of the trial for the composite primary outcome of cardiovascular death, stroke, worsening of heart failure, and myocardial infarction. Nights spent in hospital will be counted as a coprimary outcome. Usual care will consist of anticoagulation, therapy of underlying heart disease, and rate control as an initial approach. Early rhythm control therapy will consist of usual care plus rhythm control therapy by antiarrhythmic drugs, catheter ablation, and a patient-operated electrocardiographic device to monitor the ongoing rhythm. Key secondary outcomes include cognitive function and quality of life. EAST will determine whether rhythm control therapy, when applied early after the initial diagnosis of AF, can prevent cardiovascular complications associated with AF.