Early AF rhythm control

The ABC approach to AF treatment (Anticoagulation, Better symptom management, Comorbidity risk management) importantly put stroke risk mitigation as the first stage of AF management. The downside of a stepwise approach was that patients may have a number of consultations before 'rhythm control strategies are considered for symptom management; potentially after 'rate control therapies have been trialed'.

East AFNET-4 was a large trial published in 2020 that evaluated the impact of the time taken to attempt AF rhythm control.

2789 patients with AF from across Europe were randomised to receive 'rhythm control' or 'usual care' (mostly rate control medications).  They were a reasonably representative cohort- 27% were persistent AF, 40% had had previous cardioversion. The average age was 70 years and 28% had heart failure. However, all patients had AF for less than 12 months at the time of enrolment- meaning the treatments were administered relatively early in the disease process.

There's more to rhythm control than just AF ablation. Anti-arrhythmic drugs have long been the cornerstone of restoring normal sinus rhythm and when we think about 'early AF rhythm control' it's important to remember this means more than just early AF ablation.The figure below shows the strategic variety in the rhythm control group.

This study was ambitious in that it didn't look to measure the impact on AF burden or AF symptoms (we already know rhythm control strategies like ablation are good for this), it measured the relative rate of cardiovascular mortality, stroke, heart failure hospitalisation or hospitalisation from a heart attack. There was a lower rate of events in the rhythm control group and the hazard ratio was 0.79 compared to the rate control group. This meant early rhythm control was associated with a lower rate of adverse cardiovascular outcomes in this study of patients with early AF.

'AF begets AF' is a cliche in EP communities meaning AF leads to more AF burden if left untreated. Paroxysmal AF becomes persistent AF becomes long-standing persistent AF (although the rate of progression varies), harder to reverse as it becomes more established.

This well-designed study has suggested that the impact of rhythm control may go beyond symptomatic benefit; with significant improvement in morbidity and mortality in selected patients when done early. How widely these findings can be extrapolated and how the EP community can pragmatically implement changes based on these findings is to be seen and will be one of the exciting challenges in the years to come.

Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, Fetsch T, van Gelder IC, Haase D, Haegeli LM, Hamann F, Heidbüchel H, Hindricks G, Kautzner J, Kuck KH, Mont L, Ng GA, Rekosz J, Schoen N, Schotten U, Suling A, Taggeselle J, Themistoclakis S, Vettorazzi E, Vardas P, Wegscheider K, Willems S, Crijns HJGM, Breithardt G; EAST-AFNET 4 Trial Investigators. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020 Oct 1;383(14):1305-1316. doi: 10.1056/NEJMoa2019422. Epub 2020 Aug 29. PMID: 32865375.