Presenting Pattern of Atrial Fibrillation and Outcomes of Early Rhythm Control Therapy

Abstract

Background: Whether atrial fibrillation (AF) pattern or timing of AF therapy modifies the effectiveness of early rhythm control (ERC) is not known.

Objectives: This study sought to compare clinical characteristics and outcomes in patients presenting with different AF patterns on ERC vs usual care.

Methods: The effects of ERC were compared in first-diagnosed AF (FDAF), paroxysmal AF (paroxAF), and persistent AF (persAF) in this prespecified analysis of the EAST-AFNET 4 (Early treatment of atrial fibrillation for stroke prevention) trial. Associations between AF pattern and primary outcomes (first primary outcome: cardiovascular death, stroke, and hospitalization for heart failure and acute coronary syndrome; second primary outcome: nights spent in hospital per year) were compared over a mean follow-up of 5.1 years. Changes in health-related quality of life were assessed by the EQ-5D.

Results: FDAF patients (n = 1,048, enrolled 7 days after diagnosing AF) were slightly older (71 years of age, 48.0% female) than patients with paroxAF (n = 994, 70 years of age, 50.0% female) and persAF (n = 743, 70 years of age, 38.0% female). ERC reduced the primary outcome in all 3 AF patterns. Hospitalizations for acute coronary syndrome were highest in FDAF (incidence rate ratio [IRR]: 1.50; 95% CI: 0.83-2.69; P for interaction = 0.032) compared with paroxAF (IRR: 0.64; 95% CI: 0.32-1.25) and persAF (IRR: 0.50; 95% CI: 0.25-1.00). FDAF patients spent more nights in hospital (IRR: 1.38; 95% CI: 1.12-1.70; P for interaction = 0.004) than paroxAF (IRR: 0.84; 95% CI: 0.67-1.03), and persAF (IRR: 1.02; 95% CI: 0.80-1.30) patients. ERC improved health-related quality of life (EQ-5D score) in patients with paroxAF and persAF but not in patients with FDAF (P = 0.019).

Conclusions: ERC reduces the first primary composite outcome in all AF patterns. Patients with FDAF are at high risk for hospitalization and acute coronary syndrome, particularly on ERC. (Early treatment of atrial fibrillation for stroke prevention trial; ISRCTN04708680; Early Treatment of Atrial Fibrillation for Stroke Prevention Trial [EAST]; NCT01288352; Early treatment of Atrial fibrillation for Stroke prevention Trial [EAST]; EudraCT2010-021258-20).

Keywords: acute coronary syndrome; atrial fibrillation; heart failure; hospitalization; outcome; stroke; therapy.

Conflict of interest statement

Funding Support and Author Disclosures Dr Goette was partially supported by the EU Horizon 2020 MAESTRIA Consortium (grant number 965286). Dr Kirchhof was partially supported by the EU BigData@Heart (grant agreement EU IMI 116074), AFFECT-AF (grant agreement 847770), and MAESTRIA (grant agreement 965286); the British Heart Foundation (PG/17/30/32961; PG/20/22/35093; AA/18/2/34218), the German Centre for Cardiovascular Research supported by the German Ministry of Education and Research, and the Leducq Foundation. The EAST-AFNET 4 trial was supported by AFNET, the European Heart Rhythm Association, the German Centre for Cardiovascular Research, the German Heart Foundation, Sanofi, and Abbott. Dr Goette has received speaker fees from Abbott, AstraZeneca, Bayer Health Care, Berlin Chemie, Biotronik, Boehringer Ingelheim, BMS/Pfizer, Boston Scientific, Daiichi-Sankyo, Medtronic, Omeicos, Sanofi, and Viofor. Dr Camm has served as an advisor for Bayer, Daiichi-Sankyo, Pfizer/BMS, Medtronic, Boston Scientific, Abbott, Menarini, and Sanofi. Dr Kuck has served as a consultant for CardioValve; and has received grant support from Medtronic and Biosense Webster. Dr Wegscheider has served as a lecturer and statistical consultant for Biotronik, Boston Scientific, and Novartis; and has received grant support from Biotronik and Resmed. Dr Kirchhof has received research support for basic, translational, and clinical research projects from the European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (United Kingdom), and German Centre for Cardiovascular Research and from several drug and device companies active in atrial fibrillation; has received honoraria from several such companies in the past, but not in the last 3 years; and has been listed as inventor on 2 patents held by University of Birmingham (Atrial Fibrillation Therapy WO 2015140571, Markers for Atrial Fibrillation WO 2016012783). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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