The effectiveness of early rhythm control (ERC) is mediated by the presence of sinus rhythm at 12 months in patients with atrial fibrillation (AFib), based on findings from the EAST-AFNET 4 trial presented Aug. 29 during ESC Congress 2022 in Barcelona and simultaneously published in the European Heart Journal.

Researchers used the EAST-AFNET 4 data set and identified 14 potential mediators of the effect of ERC in the total study population at 12-month follow up visit and further interrogated by use of a four-way decomposition of the treatment effect in an exponential model predicting future primary outcome events.

Overall findings found sinus rhythm at 12 months explained 81% of the treatment effect of ERC compared with usual care during the remainder of follow up (4.1 years). In patients not in sinus rhythm at 12 months, ERC did not reduce future cardiovascular outcomes (hazard ratio 0.94, 95% confidence interval 0.65-1.67). Inclusion of AFib recurrence in the model only explained 31% of the treatment effect, researchers said. Additionally, inclusion of systolic blood pressure at 12 months only explained 10%. There was no difference in outcomes in patients who underwent AFib ablation compared with those who did not undergo the procedure.

"Clinicians implementing ERC should aim for rapid and sustained restoration of sinus rhythm in patients with recently diagnosed AFib and cardiovascular comorbidities," said Lars Eckardt, MD, et al. "Future trials may explore the best therapy for patients who are not in sinus rhythm after 1 year of ERC. Until such trials report, a careful balance of the expected effectiveness and safety of further rhythm control therapy seems warranted," they add.

Clinical Topics: Arrhythmias and Clinical EP, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: ESC Congress, ESC22, Atrial Fibrillation, Blood Pressure

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