Analysis sets out generalisability of EAST-AFNET 4 trial findings

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Paulus Kirchhof

Around 80% of patients diagnosed with atrial fibrillation (AF) in the UK population are eligible for early rhythm control, an analysis of the EAST-AFNET 4 trial, published in Heart, has found.

Rhythm control therapy is typically delayed unless patients have persistent symptoms on otherwise effective rate control. EAST-AFNET 4 investigated whether rhythm control therapy—with antiarrhythmic drugs or ablation—delivered soon after diagnosis improves outcomes.

Results of the trial, delivered at 2020 European Society of Cardiology Congress (ESC 2020, 29 August–1 September, virtual) and published in The New England Journal of Medicine, led investigators to conclude that rhythm control therapy, initiated soon after diagnosis of AF, reduces cardiovascular complications without increasing time spent in hospital and without safety concerns.

In the latest study, investigators sought to quantify the generalisability of the trial’s results, assessing the eligibility of participants in the population-based UK Biobank based upon the EAST-AFNET 4 inclusion and exclusion criteria.

Treatment of all eligible participants was classified as early rhythm control, using an antiarrhythmic drug therapy or AF ablation, or usual care, and efficacy and safety outcomes were compared between groups in the entire cohort and in a propensity-matched data set.

Reporting the results in Heart, the study’s authors, including EAST-AFNET 4 lead investigator Paulus Kirchhof (University Heart and Vascular Centre UKE Hamburg, Hamburg, Germany and University of Birmingham, Birmingham, UK), write that AF was diagnosed in 35,526 out of a total of 502,493 UK Biobank participants (7.1%).

At the time of enrolment, they report that AF was prevalent in 8,340 participants, and 27,186 participants developed AF during follow-up. A total of 7,352 participants had prevalent AF (>one year) prior to their UK Biobank enrolment and were excluded from further analyses.

Out of 988 participants enrolled within a year of the first diagnosis of AF, 647 (65.49%) were eligible for early rhythm control therapy, while out of 27,186 participants with incident AF, 22,003 participants (80.94%) were eligible for early rhythm control.

“The present analysis demonstrates that most participants (approximately 80%), with newly detected AF, are eligible for early rhythm control in a large, population-based sample,” the study authors write.

Furthermore, the investigators report that eligible participants were older (70 years vs. 63 years) and more likely to be female (42% vs. 21%) compared with ineligible patients, and safety outcomes were found not to be different between patients receiving early rhythm control and controls.

The primary outcome of EAST-AFNET 4, a composite of cardiovascular death, stroke/transient ischaemic attack and hospitalisation for heart failure or acute coronary syndrome occurred less often in participants receiving early rhythm control compared with controls in the entire cohort (hazard ratio 0.82, 95% confidence interval 0.71–0.94, p=0.005), the study authors add.

“Early rhythm control should become a routine part of the clinical management of most patients with recently diagnosed AF,” the study’s authors write in their concluding remarks.


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