A 55-year-old female patient was referred to the electrophysiology clinic by her primary cardiologist. She has a history of coronary artery disease, type 2 diabetes mellitus and hypertension, and was recently hospitalized for acute pancreatitis 4 months ago. An electrocardiogram (ECG) performed during admission revealed atrial fibrillation (AF) with controlled ventricular rate. She did not carry a diagnosis of AF prior to this hospitalization and was intermittently in AF during her hospitalization. She was discharged with apixaban after risk/benefit discussions regarding her CHA2DS2-VASc score of 3 with close cardiology follow-up. Today she is feeling well, denied ever having symptoms, and her ECG showed AF. Her medications include aspirin 81 mg daily, lisinopril 20 mg daily, metformin 1000 mg daily, atorvastatin 40 mg daily, and apixaban 5 mg twice daily. Her stress echocardiography performed last year showed no ischemic abnormalities and normal biventricular function.
Which of the following is the best strategy to manage the patient's AF to prevent future cardiovascular adverse events?
Show Answer
The correct answer is: E. Discuss possible rhythm control options.
Recently, more evidence is pointing to the benefit of achieving rhythm control in patients with AF as first-line therapy. The EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention) trial investigated whether an early rhythm-control strategy including antiarrhythmic drugs (AAD) and AF ablation improved outcomes in patients with cardiovascular diseases. A total of 2,789 patients with early AF (diagnosed ≤12 months before enrollment) were randomized to early rhythm-control strategy versus usual care in a 1:1 fashion. The primary outcome of composite of death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome occurred in 249 of the patients assigned to early rhythm control (3.9 per 100 person-years) and in 316 patients assigned to usual care (5.0 per 100 person-years) (HR 0.79; CI, 0.66 to 0.94; P = 0.005).1 A pre-specified analysis of the study compared the effect of early rhythm-control therapy in asymptomatic to symptomatic patients and revealed no difference in outcomes regardless of symptoms. The primary outcome occurred in 79 of 395 asymptomatic patients in the early rhythm-control therapy group and in 97 of 406 patients in the usual care group (HR 0.76, CI 0.6-1.03).2
This patient most likely has paroxysmal AF that was diagnosed within the past 4 months. Despite the lack of symptoms, her significant cardiovascular comorbidities suggest that early rhythm-control strategies such as AADs or AF ablation can be beneficial compared to usual care.
References
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.
Willems S, Borof K, Brandes A, et al. Systematic, early rhythm control strategy for atrial fibrillation in patients with or without symptoms: the EAST-AFNET 4 trial. Eur Heart J 2021:[Epub ahead of print].
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