Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial-Reference-Cited by-同舟云学术

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

Published:2021-08-27 Issue: Volume: Page:
ISSN:0195-668X
Container-title:European Heart Journal
language:en
Short-container-title:

Author:

Willems Stephan¹²³,Borof Katrin⁴,Brandes Axel⁵⁶^ORCID,Breithardt Günter³⁷^ORCID,Camm A John⁸,Crijns Harry J G M⁹,Eckardt Lars³⁷,Gessler Nele¹²^ORCID,Goette Andreas⁶¹⁰¹¹,Haegeli Laurent M¹²¹³,Heidbuchel Hein¹⁴,Kautzner Josef¹⁵,Ng G André¹⁶^ORCID,Schnabel Renate B²⁴^ORCID,Suling Anna¹⁷,Szumowski Lukasz¹⁸,Themistoclakis Sakis¹⁹^ORCID,Vardas Panos²⁰,van Gelder Isabelle C²¹,Wegscheider Karl²³¹⁵^ORCID,Kirchhof Paulus²³⁴²²^ORCID

Affiliation:

1. Asklepios Hospital St. Georg, Department of Cardiology and Internal intensive care medicine, Faculty of Medicine, Semmelweis University Campus Hamburg, Hamburg, Germany

2. DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Berlin, Germany

3. Atrial Fibrillation Network (AFNET), Münster, Germany

4. Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg, Martinistraße 52, Hamburg 20246, Germany

5. Department of Cardiology, Odense University Hospital, Denmark

6. Department of Clinical Research, University of Southern Denmark, Odense, Denmark

7. Department of Cardiology II (Electrophysiology), University Hospital Münster, Germany

8. Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George’s University of London, UK

9. Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Netherlands

10. St. Vincenz Hospital, Paderborn, Germany

11. Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Germany

12. University Hospital Zurich, Zurich, Switzerland

13. Division of Cardiology, Medical University Department, Kantonsspital Aarau, Switzerland

14. University Hospital Antwerp and Antwerp University, Antwerp, Belgium

15. Institute for Clinical and Experimental Medicine, Prague, Czech Republic

16. Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK

17. Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg, Eppendorf, Germany

18. Arrhythmia Center of the National Institute of Cardiology, Medical Division of Cardinal Stefan Wyszynski University in Warsaw, Warsaw, Poland

19. Department of Cardiology, Ospedale dell’Angelo, Venice, Italy

20. Heart Sector, Hygeia Hospitals Group, Athens, Greece

21. University of Groningen, University Medical Center Groningen, Groningen, Netherlands

22. Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK

Abstract

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).

Funder

AFNET, DZHK, EHRA, Deutsche Herzstiftung (DHS), Abbott Laboratories, and Sanofi

European Union BigData@Heart

British Heart Foundation

German Ministry of Education and Research

Leducq Foundation

European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme

European Union’s Horizon 2020 research and innovation programme

German Center for Cardiovascular Research

German Ministry of Research and Education

ERACoSysMed3

Publisher