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Reduced cardiovascular outcomes with early rhythm control

Presented by
Prof. Paulus Kirchhof, University Heart & Vascular Center Hamburg, Germany
ESC 2020


Early initiation of rhythm control reduced cardiovascular outcomes in patients with early atrial fibrillation (AF) and comorbid cardiovascular conditions compared with contemporary, evidence-based usual care [1]. Although early rhythm control was associated with more adverse events, the overall safety of both strategies was comparable and did not affect the number of nights spent in hospital per year. These findings of the EAST-AFNET 4 trial were published simultaneously in the New England Journal of Medicine [2].

Even with current guideline-based management, approximately 5% of AF patients suffer acute coronary syndrome, heart failure, stroke, or cardiovascular death per year [2]. There is an increased risk of cardiovascular complications during the first year after AF is diagnosed. Researchers have hypothesised that rhythm-control therapy may be more effective when delivered early, but evidence supporting this notion was lacking in patients with confirmed AF.

The EAST-AFNET 4 trial, presented by Prof. Paulus Kirchhof (University Heart & Vascular Center Hamburg, Germany), attempted to address this unmet need. The EAST-AFNET 4 investigators enrolled 2,789 patients with early AF (median time since diagnosis 36 days) and cardiovascular conditions, who randomly received either early rhythm control or usual care. Early rhythm control included treatment with antiarrhythmic drugs or AF ablation after randomisation, while usual care limited rhythm control to the management of AF-related symptoms. The first primary outcome was a composite of death from cardiovascular causes, stroke, or hospitalisation with worsening heart failure or acute coronary syndrome.

After a median follow-up of 5.1 years, the trial was stopped prematurely for efficacy at the third interim analysis because a first primary-outcome event occurred in 249 of the patients assigned to early rhythm control (3.9 per 100 person-years) and in 316 patients assigned to usual care (5.0 per 100 person-years) (HR 0.79; 95% CI 0.66-0.94; P=0.005; see Table).

Table: Efficacy Outcomes of the EAST-AFNET 4 trial [2]

*P=0.005 for the between group comparison.

The EAST-AFNET 4 trial showed that early rhythm-control therapy was associated with a lower risk of cardiovascular outcomes than usual care among patients with early AF and cardiovascular conditions. These results have the potential to inform the future use of rhythm control therapy, further improving the care of patients with early AF.


    1. Kirchhof P. EAST – AFNET 4: Effects of early rhythm control therapy in patients with atrial fibrillation. Hot Line 1, ESC Congress 2020, 29 Aug.
    2. Kirchhof P, et al. New Engl J Med. 2020, August 29. DOI: 10.1056/NEJMoa2019422.


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