An international team including researchers from the National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, has found that patients who were diagnosed with atrial fibrillation (AF) in the past 12 months benefit from early rhythm control therapy.
The ‘Early treatment of Atrial fibrillation for Stroke prevention Trial’ (EAST-AFNET 4) was co-ordinated by the Atrial Fibrillation Network (AFNET) and the European Heart Rhythm Association (EHRA). The findings are presented at the European Society of Cardiology (ESC) Congress today (29 August 2020) and simultaneously published in the New England Journal of Medicine.
AF is a common heart rhythm disturbance where parts of the heart ‘misfire’, which causes the heart to beat irregularly and often more quickly. Patients with the condition can have dizzy spells, heart palpitations and shortness of breath. AF affects 1-2 per cent of the general population, or one in 10 people over the age of 70, and increases the risk of stroke by five times.
According to national and international guidelines, rhythm control therapy is typically delayed unless patients have persistent symptoms even when their heart rate is under good control through simple medication, such as beta blockers.
In the EAST-AFNET 4 study 2,789 patients with early AF and cardiovascular risk factors, such as high blood pressure and diabetes, were recruited to the study. Participants were assigned to either early rhythm control therapy or usual care. Those on the early rhythm control therapy arm were given special antiarrhythmic medicine or AF ablation – a procedure that freezes or burns areas of the heart that are ‘misfiring’. Patients in both groups received guideline-recommended anticoagulation treatment (medicine to thin the blood and prevent clotting) to prevent a stroke.
Patients in the rhythm control therapy group were given additional treatment with more specific drugs and ablation if they were found to have recurrent AF. Patients in the usual care group were managed initially with rate control but if their symptoms worsened, they were offered rhythm control therapy, following current clinical guidelines.
The researchers found that using early rhythm control therapy, with antiarrhythmic medicines, AF ablation or a combination of the two treatments, significantly reduced the likelihood of stroke, hospitalisation for worsening heart failure, and early death, compared to usual care.
Principal investigator Professor Paulus Kirchhof of the University Heart and Vascular Centre UKE Hamburg, Germany and the University of Birmingham, UK, said: “Rhythm control therapy initiated soon after diagnosis of atrial fibrillation reduced cardiovascular outcomes in patients with early AF and cardiovascular conditions without increasing time spent in hospital and without safety concerns. These results have the potential to completely change clinical practice towards rhythm control therapy early after the diagnosis of atrial fibrillation.
“The risk of severe cardiovascular outcomes and death in patients with atrial fibrillation is highest in the first year after diagnosis, suggesting that early rhythm control therapy could be most beneficial. Furthermore, atrial fibrillation causes atrial damage within a few weeks of disease onset. Early rhythm control therapy could reduce or prevent this damage, making it more effective.”
Professor Andre Ng, chief investigator in the UK for the EAST-AFNET 4 study and head of the cardiovascular sciences department at the University of Leicester, said: “This is a major landmark study and provides robust data that supports the early rhythm control treatment of AF over and above what we are normally doing according to current guidelines. This would trigger a rethink of the guidance and emphasises the importance of early diagnosis.
“We need to increase the awareness in patients and clinicians, improve our effort in picking up AF early in patients, with the early diagnosis implement blood thinners in patients who need them and consider a rhythm control approach and not wait and see if the rate control approach works. This applies to patients across different subgroups – including patients who are not symptomatic, with and without heart failure, or have increased BMI. This requires a much more proactive approach all round. The data advises against complacency in care and the message is unequivocal.”