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

Stephan Willems; Katrin Borof; Axel Brandes; Günter Breithardt; A John Camm; Harry J G M Crijns; Lars Eckardt; Nele Gessler; Andreas Goette; Laurent M Haegeli; Hein Heidbuchel; Josef Kautzner; G André Ng; Renate B Schnabel; Anna Suling; Lukasz Szumowski; Sakis Themistoclakis; Panos Vardas; Isabelle C van Gelder; Karl Wegscheider; Paulus Kirchhof

doi:10.1093/eurheartj/ehab593

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

Stephan Willems, Katrin Borof, Axel Brandes, Günter Breithardt, A John Camm, Harry J G M Crijns, Lars Eckardt, Nele Gessler, Andreas Goette, Laurent M Haegeli, Hein Heidbuchel, Josef Kautzner, G André Ng, Renate B Schnabel, Anna Suling, Lukasz Szumowski, Sakis Themistoclakis, Panos Vardas, Isabelle C van Gelder, Karl WegscheiderPaulus Kirchhof^*

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

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).

Original language	English
Pages (from-to)	1219-1230
Number of pages	12
Journal	European Heart Journal
Volume	43
Issue number	12
Early online date	27 Aug 2021
DOIs	https://doi.org/10.1093/eurheartj/ehab593
Publication status	Published - 21 Mar 2022

Keywords

Atrial fibrillation
Symptoms
Rhythm control
Ablation
Antiarrhythmic drugs
Clinical trial
CATHETER ABLATION
RADIOFREQUENCY ABLATION
OUTCOMES
MANAGEMENT
THERAPY

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Willems, S., Borof, K., Brandes, A., Breithardt, G., Camm, A. J., Crijns, H. J. G. M., Eckardt, L., Gessler, N., Goette, A., Haegeli, L. M., Heidbuchel, H., Kautzner, J., Ng, G. A., Schnabel, R. B., Suling, A., Szumowski, L., Themistoclakis, S., Vardas, P., van Gelder, I. C., ... Kirchhof, P. (2022). Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial. European Heart Journal, 43(12), 1219-1230. https://doi.org/10.1093/eurheartj/ehab593

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title = "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).",

keywords = "Atrial fibrillation, Symptoms, Rhythm control, Ablation, Antiarrhythmic drugs, Clinical trial, CATHETER ABLATION, RADIOFREQUENCY ABLATION, OUTCOMES, MANAGEMENT, THERAPY",

author = "Stephan Willems and Katrin Borof and Axel Brandes and G{\"u}nter Breithardt and Camm, {A John} and Crijns, {Harry J G M} and Lars Eckardt and Nele Gessler and Andreas Goette and Haegeli, {Laurent M} and Hein Heidbuchel and Josef Kautzner and Ng, {G Andr{\'e}} and Schnabel, {Renate B} and Anna Suling and Lukasz Szumowski and Sakis Themistoclakis and Panos Vardas and {van Gelder}, {Isabelle C} and Karl Wegscheider and Paulus Kirchhof",

note = "{\textcopyright} The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.",

year = "2022",

month = mar,

day = "21",

doi = "10.1093/eurheartj/ehab593",

language = "English",

volume = "43",

pages = "1219--1230",

journal = "European Heart Journal",

issn = "0195-668X",

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Willems, S, Borof, K, Brandes, A, Breithardt, G, Camm, AJ, Crijns, HJGM, Eckardt, L, Gessler, N, Goette, A, Haegeli, LM, Heidbuchel, H, Kautzner, J, Ng, GA, Schnabel, RB, Suling, A, Szumowski, L, Themistoclakis, S, Vardas, P, van Gelder, IC, Wegscheider, K & Kirchhof, P 2022, 'Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial', European Heart Journal, vol. 43, no. 12, pp. 1219-1230. https://doi.org/10.1093/eurheartj/ehab593

TY - JOUR

T1 - Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms

T2 - the EAST-AFNET 4 trial

AU - Willems, Stephan

AU - Borof, Katrin

AU - Brandes, Axel

AU - Breithardt, Günter

AU - Camm, A John

AU - Crijns, Harry J G M

AU - Eckardt, Lars

AU - Gessler, Nele

AU - Goette, Andreas

AU - Haegeli, Laurent M

AU - Heidbuchel, Hein

AU - Kautzner, Josef

AU - Ng, G André

AU - Schnabel, Renate B

AU - Suling, Anna

AU - Szumowski, Lukasz

AU - Themistoclakis, Sakis

AU - Vardas, Panos

AU - van Gelder, Isabelle C

AU - Wegscheider, Karl

AU - Kirchhof, Paulus

PY - 2022/3/21

Y1 - 2022/3/21

N2 - 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).

AB - 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).

KW - Atrial fibrillation

KW - Symptoms

KW - Rhythm control

KW - Ablation

KW - Antiarrhythmic drugs

KW - Clinical trial

KW - CATHETER ABLATION

KW - RADIOFREQUENCY ABLATION

KW - OUTCOMES

KW - MANAGEMENT

KW - THERAPY

U2 - 10.1093/eurheartj/ehab593

DO - 10.1093/eurheartj/ehab593

M3 - Article

C2 - 34447995

SN - 0195-668X

VL - 43

SP - 1219

EP - 1230

JO - European Heart Journal

JF - European Heart Journal

IS - 12

ER -