Early rhythm control one year after atrial fibrillation (AF) diagnosis has been found to be beneficial in preventing recurrent stroke in patients with incident AF and a prior history of stroke. Published in JACC: Clinical Electrophysiology, researchers suggest that integrated care, including optimal rhythm control with appropriate anticoagulation, should be considered in this population.
Lead researcher So-Ryoung Lee (Seoul National University Hospital, Seoul, Republic of Korea) and colleagues accessed the Korean national database to identify newly diagnosed patients with AF in the period between January 2010 and December 2016 to evaluate the role of early rhythm control on the reduction of future stroke.
The early rhythm control was defined as the prescription of anti-arrhythmic drugs (AAD [class Ic or class III]), receiving direct current cardioversion (DCC), or AF catheter ablation within one year after AF diagnosis, the alternate group were defined as the usual care group. Incident stroke was assessed as the researchers’ primary outcome during follow-up, which spanned one year to the incidence of outcome event, death or the end of the study period—whichever occurred first.
A total of 53,509 patients were evaluated—12,455 in the rhythm control group and 41,054 in the usual care group—who were all prescribed oral anticoagulants. In a median period of 2.6 years, 4,382 patients had an incident stroke. Stroke occurred in 751 patients receiving rhythm control and in 3,631 patients among the usual care group, and the crude IRs were 1.98 per 100 person-years and 2.84 per 100 person-years, respectively—demonstrating a 28% lower risk of recurrent stroke for patients in the early rhythm control group.
Although it was not Lee et al’s primary purpose to compare the risk of stroke among various rhythm control strategies, they performed an analysis on each strategy in comparison to usual care, showing relative risk reduction for all rhythm control strategies when contrasted.
Iterating the established risk factor of future stroke in patients with AF—and the 2.2-fold increased risk in those who have had a prior stroke in both anticoagulated and non-anticoagulated groups—the authors, with the confluence of previous studies, approach generalising their results with relative caution. They emphasise that as each strategy was “not fully independent” but largely overlapped—particularly the majority of patients who received DCC or AF catheter ablation that continued AAD for long-term rhythm maintenance.
Lee and colleagues conclude that for patients with AF who experience acute stroke, “a study to demonstrate the benefit of early rhythm control compared with usual care with rate control is ongoing”. Further clinical trials are needed to confirm the benefit of early rhythm control in patients with AF with stroke in various clinical situations.”