Early Rhythm-Control Therapy in Patients with Atrial Fibrillation

Rate vs. rhythm control of atrial fibrillation has been a perennial question.

These investigators sough to determine if patients with “early atrial fibrillation” (<1 year since diagnosis) and cardiovascular conditions had better outcomes with rhythm control.

The was a behemoth study and worthy of publication in the NEJM.

2789 patients in 135 centres in 11 different countries in Europe were randomised to either rhythm control (antiarrhythmic drugs, ablation, & cardioversion) vs. usual care (mostly rate control but occasionally rhythm control to manage AF related symptoms.)

One primary outcome was a composite of death from cardiovascular cause, hospitalisation for heart failure and/or ACS. The other primary outcome was nights spent in hospital. There were lots of secondary and safety outcomes.

After a median 5 year per patient follow up time, the trial was stopped early due to efficacy at the 3^rd interim analysis. There was an absolute decrease of 1.1 events per 100 person years for the first primary outcome. This may not seem like much of a treatment effect, but there are a lot of people out there with AF.

No study is perfect, and this one has some limitations. There were reasonably narrow inclusion criteria which limit generalisability. It probably excluded most symptomatic patients as they would not have been candidates to be randomised to “usual care.” In the manuscript, there is an entire column of author conflicts of interest- in small font no less! Cardiologist love to cosy up to industry….

Either way, this study will change the guidelines. And in speaking with my local electrophysiologist, this study has already changed practice. Cardiologists are pushing suitable patients with new AF towards a rhythm control strategy with antiarrhythmics and more ablations are being performed.

Of course, emergency physicians are not likely to prescribe antiarrhymics and certainly won’t do ablations (unless you want a friendly visit from a regulatory body). But it is good for us to know the overall strategy and we will be asked to be more aggressive with early rhythm control.

Covering:

Kirchhof P, Camm AJ, Goette A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020;383:1305-16. [link to article]