Rhythm control in asymptomatic ‘early’ atrial fibrillation: birth of a new paradigm?

In December 1911, Sir Thomas Lewis wrote in his iconic book Clinical Disorders of the Heart Beat: ‘There is no ailment in which such success can be achieved, no other cardiac disease which can be so speedily benefited, as the well managed case of auricular fibrillation’.1

He probably did not expect that his intuitive, observational therapeutic enthusiasm would have needed more than a century to become cemented by solid scientific evidence. However, before achieving this goal, our approach in the last two decades has been rather nihilistic: we have managed patients with atrial fibrillation (AF) as though the benefits of rate and rhythm control strategies were similar. In other words, we have believed for quite a long time that in most patients with AF it is not worth struggling to restore and maintain sinus rhythm. This was the clinical message not only from the AFFIRM trial but also from other randomized trials, one of them conducted in patients with AF and heart failure—the CHF-AF trial.2,4

Last year the results of the EAST-AFNET 4 trial set a new landmark in our efforts to minimize adverse cardiovascular outcomes in patients with AF.5 This international, multicentre, randomized parallel-group trial enrolled 2789 patients with recent AF (diagnosed ≤1 year before enrolment with a median of 36 days). They were randomized to either early rhythm control or usual care. Early rhythm control was based on drugs and/or catheter ablation. In the usual care arm, rhythm control was driven only by arrhythmic symptoms. The strategy of initiating rhythm control soon after diagnosing AF (the authors introduce the term ‘early’ AF) was associated with a lower risk of the primary endpoint, a composite of death from cardiovascular causes, stroke, or hospitalization for heart failure or acute coronary syndrome, as compared with standard care over the following 5 years. Occurrence of the primary endpoint was 3.9 vs. 5.0 per 100 person-years in the early rhythm control arm and in the usual care arm, respectively [absolute difference 1.1 per 100 person-years; hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.66–0.94; P = 0.005].

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