Deep dive into EAST-AFNET 4 results on early rhythm-control in atrial fibrillation

Results from the EAST-AFNET 4 suggested that early, structured rhythm control therapy based on antiarrhythmic drugs and catheter ablation reduced atrial fibrillation (AF)-related complications when compared with usual care. A clear explanation for this benefit did not emerge from a closer look at the data [1].

Dr Andreas Metzner (University Heart & Vascular Centre Hamburg, Germany) presented an analysis of the EAST-AFNET 4 study (NCT01288352) focussing on the components of AF management and treatment patterns. The EAST-AFNET 4 study was designed to evaluate the effects of early rhythm control on the composite primary endpoint of cardiovascular death, stroke, hospitalisation for heart failure or acute coronary syndrome [2]. Participants (n=2,789) were randomised into 2 study arms: one receiving usual care (n=1,394) and the other receiving early rhythm-control therapy (n=1,395). Mean follow-up time was 5.1 years/patient.

Results showed a 21% risk reduction for cardiovascular death, stroke, hospitalisation for heart failure or acute coronary syndrome in patients receiving early rhythm control. To derive treatment recommendations from this important finding and to evaluate the impact of clinical benefit or additional disease management, treatment patterns were further analysed [1].

Over 90% of patients received oral anticoagulation therapy, with more than 54% of patients receiving direct oral anticoagulants (DOACs) in both groups. Furthermore, there was no difference in treatment of heart failure, hypertension (~70% of patients), or diabetes. Rate control therapy was used in 4 out of 5 patients in both study arms, with a larger proportion of patients receiving beta blocker-monotherapy in the control group. The use of rate control therapy slightly decreased over time in both groups.

The number of in-person follow-up visits was low in both study arms: 1.94 versus 2.13 visits/patient, with the higher number in the treatment arm being derived from more frequent visits after randomisation to adjust rhythm-control therapy.

In usual care, rhythm control remained the exception. Antiarrhythmic drug therapy in the treatment arm was initially given to 84% of patients, with 45% of patients still receiving antiarrhythmic drugs after 2 years. AF ablation was typically performed on patients on antiarrhythmic drugs, likely reflecting recurrent AF. While the proportion of patients receiving ablation was higher in the treatment arm, the numbers increased over time in both groups in a parallel manner. Predictors for AF ablation therapy were country of enrolment and enrolment to an ablation site, indicating that local availability played an important role.

Dr Metzner concluded: “Systematic and early rhythm control results in clinical benefit when added to evidence-based oral anticoagulation, therapy of concomitant cardiovascular conditions, and rate control therapy. The clinical benefit of early rhythm control was achieved without many additional visits and with regionally different treatment choices within guideline recommendations.”

1. 
   
   1. Metzner A. Components of AF management and early rhythm control in patients with atrial fibrillation: a detailed analysis of the EAST-AFNET 4 dataset. EHRA 2021 Congress, 23-25 April.
   2. Kirchhof P, et al. N Engl J Med 2020;383:1305-16.

 

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Posted on 16 June 20216 September 2023