Rhythm Control of Atrial Fibrillation

Current guidelines for the management of atrial fibrillation (AF) recommend an initial approach of either rate control or rhythm control of the arrhythmia based on patient symptoms and preferences.However, AF is a progressive condition that is associated with significant cardiovascular morbidity and mortality.It is biologically plausible that early intervention to prevent the adverse atrial electric, structural, and autonomic remodeling associated with AF might reduce the risk of adverse cardiac outcomes.Until recently, though, empirical evidence for this reasoning has been lacking, because previous randomized clinical trials that failed to find clinical outcomes benefits of rhythm control over rate control predominantly included patients with well-established AF and did not include AF ablation as a rhythm control option.The EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention) trial tested the hypothesis that a strategy of early rhythm control therapy that included AF ablation would reduce the risk of adverse cardiovascular outcomes compared with usual care. 1 Patients with early AF (defined as AF diagnosed ≤12 months before enrollment) and underlying cardiovascular conditions (n=2796) were enrolled a median of 36 days after AF diagnosis.More than one-third were enrolled with their first episode of AF, and 30% were asymptomatic from AF (European Heart Rhythm Association class I).Those randomized to early rhythm control were cardioverted if AF was persistent, and initially treated with antiarrhythmic drugs (87%) or AF ablation (8%).By 2 years' follow-up, 19% of participants had undergone AF ablation.Those in the usual care group were treated with rate control therapy that followed AF guidelines and could only cross over to rhythm control for management of ongoing AF-related symptoms.At 2 years, 15% had switched to rhythm control.After a median follow-up of 5.1 years, patients who were randomly assigned to early rhythm control had a lower risk of death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome (hazard ratio [HR], 0.79 [96% CI, 0.66-0.94];P=0.005).The estimated benefits in this end point were similar across baseline European Heart Rhythm Association AF symptom classes.These patients also experienced a lower risk of 2 of the individual end point components: death from cardiovascular causes (HR, 0.72 [95% CI, 0.52-0.98])and stroke (HR, 0.65 [95% CI, 0.44-0.97]).There was no significant difference in the second primary end point of mean number of nights spent in the hospital between treatment groups (5.8±21.9 and 5.1±15.5 days per year for early rhythm control and usual care, respectively; P=0.23).Rhythm control-related adverse events occurred in 4.9% of patients, with drug-related bradycardia being the most common event.Adverse effects were less frequent and occurred in 1.4% of those receiving usual care. Some limitations of the EAST-AFNET 4 trial design and execution merit discussion. A greater proportion of patients in the early rhythm control group withdrew Rhythm Control of Atrial FibrillationThe Earlier the Better?

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