The skeptical cardiologist has been a strong advocate of the maintenance of sinus rhythm in patients with atrial fibrillation (AF) using enlightened medical management. I was pleased, therefore, to see the results of the EAST-AFNET trial which were presented at the European Society of Cardiology Meeting this week and published in NEJM simultaneously.
This multicenter European study randomized patients with relatively new onset, median 26 days earlier and
“(diagnosed ≤1 year before enrollment) and cardiovascular conditions to receive either early rhythm control or usual care. Early rhythm control included treatment with antiarrhythmic drugs or atrial fibrillation ablation after randomization. Usual care limited rhythm control to the management of atrial fibrillation–related symptoms.
2789 patients were randomized and followed for an average 5.1 years for multiple cardiac related outcomes:
The first primary outcome was a composite of death from cardiovascular causes, stroke, or hospitalization with worsening of heart failure or acute coronary syndrome; the second primary outcome was the number of nights spent in the hospital per year. The primary safety outcome was a composite of death, stroke, or serious adverse events related to rhythm-control therapy.
The majority of patients in the treatment arm (the columns on the left at baseline and after 2 years treatment) were initially treated with one of the two drugs I use almost exclusively and have written about in detail (flecainide here and amiodarone here.)
I was also pleased to see that only 8% of patients underwent early AF ablation but was surprised to see so much dronedarone usage (a drug I avoid) but do note that only 5.9% were taking it at 2 years.
Here are the results showing the lower events including death from CV cause and stroke with the rhythm control strategy (maintenance of sinus rhythm.)
I have to dig into this study in more detail to put it in perspective but for now it provides for me more evidence that an enlightened approach to medical management of AF for maintenance of normal rhythm is the best approach for most patients.