ESC 2020 — Early rhythm control is favorable in Afib

  • Pavankumar Kamat
  • Conference Reports
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  • Early rhythm control with antiarrhythmic drugs and/or ablation in patients with recently diagnosed Afib significantly lowered the risk for major adverse cardiovascular outcomes compared with rate control.

Why this matters

  • Previous studies of rate vs rhythm control in Afib, such as the AFFIRM trial, failed to demonstrate an advantage for rhythm over rate control in terms of clinical outcomes.

Study design

  • EAST-AFNET 4: a multicenter prospective, open, blinded-outcome-assessment trial included patients with early Afib and an average CHA2DS2-VASc score of 3.4, randomly assigned to either early rhythm control (n=1395) or guideline-recommended rate control (n=1394).
  • Primary endpoint was a composite of cardiovascular death, stroke, acute coronary syndrome, or hospitalization for heart failure.
  • Funding: German Ministry of Education and Research; others.

Key results

  • At a median of 5.1 years follow-up, the primary endpoint occurred at a rate of 3.9% per year in the early rhythm control group vs 5% per year in the rate control group. 
  • This outcome corresponds to a 21% (P=.005) relative risk reduction favoring early rhythm control.
  • The co-primary endpoint of the mean number of nights spent in the hospital annually was comparable between rhythm (5.8±21.9 days/year) and rate control groups (5.1±15.5 days/year; P=.23).
  • Rates of serious adverse events were 4.9% with early rhythm control vs 1.4% with rate control.


  • Open-label.
  • Safety and efficacy of specific components of early rhythm control were not assessed.

Expert commentary

  • Paulus Kirchhof, MD, who presented the study, said: "My conclusion is that every patient with newly diagnosed Afib and a CHA2DS2-VASc score of 2 or more should not only receive anticoagulation and rate control, but should also be offered rhythm control therapy at the time of diagnosis, which also means that all of these people have to be seen by a cardiologist who has expertise in the domain of Afib management."