Perspective:

The EAST-AFNET 4 trial showed that early rhythm control therapy was associated with a lower risk of adverse cardiovascular outcomes than usual care among patients with early atrial fibrillation and cardiovascular conditions. The study employed both pharmacological and procedural means of achieving sinus rhythm, and it is one of the most impactful studies in the field of AF management in the last several years. The current report shows that early rhythm control reduces the first primary composite outcome in all AF patterns; first-diagnosed, paroxysmal, and persistent. However, patients with first-diagnosed AF are at a higher risk of hospitalization and acute coronary syndrome, particularly if they are treated with early rhythm control strategy. Those factors may help explain reduced quality-of-life measures in first-diagnosed AF patients compared to the other groups. It is not clear why first-diagnosed AF should have an increased risk, but it is possible that AF is being triggered by underlying pathophysiological processes which may be secondary to acute changes in the underlying health status. This should be explored in future investigations.