Early Rhythm-Control Therapy in Patients with Atrial Fibrillation
RCT (n=2789) stopped for efficacy at 3rd interim analysis after median of 5.1 years follow-up/patient found early rhythm-control therapy linked to lower risk of CV outcomes vs. usual care among patients with early AF and CVD, with no significant difference in safety outcome.
Source:
New England Journal of Medicine
SPS commentary:
In study, a first-primary-outcome event (composite of death from CV causes, stroke, or hospitalisation with worsening of heart failure or acute coronary syndrome) occurred in 249 patients assigned to early rhythm control (treatment with antiarrhythmic drugs or AF ablation: 3.9 per 100 person-years) and in 316 patients assigned to usual care (management of AF–related symptoms: 5.0 per 100 person-years [hazard ratio, 0.79; 96% CI, 0.66 to 0.94; p=0.005].
According to an editorial, the AFFIRM trial found no significant differences between rhythm control and rate control at 5 years with respect to mortality or the percentage of patients with ischaemic stroke and meta-analysis of 5 RCTs of rhythm control as compared with rate control likewise showed no significant differences with respect to all-cause mortality and stroke, although the results appeared to favour rate control. Therefore, rate-control strategies are used preferentially, and rhythm-control strategies are recommended primarily to improve AF–related symptoms. It notes the strongest predictor of survival in AFFIRM was not the presence of sinus rhythm but the use of warfarin, which was continued in 70% of patients; ischaemic strokes in either treatment group largely occurred in patients in whom anticoagulation was withheld. In the current study, the use of anticoagulation was common and continued over time (~90% patients in both groups at 2 years), and the incidence of stroke was correspondingly low. It adds that a limitation of this study, with its low event rates, was that 9.0% and 6.6% of follow-up years in the early-rhythm-control group and usual-care group, respectively, were lost because patients withdrew from the trial or were lost to follow-up. It concludes overall that the results of this trial support the use of rhythm control to reduce AF-related adverse clinical outcomes when applied early in the treatment of patients with AF and the use of other cardiovascular therapies (including anticoagulants, renin–angiotensin–aldosterone system inhibitors, beta-blockers, and statins) in the trial probably contributed to the low rates of stroke, heart failure, acute coronary syndrome, and death and highlight the need to treat AF with comprehensive management strategy.