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Linz D, Andrade JG, Arbelo E, Boriani G, Breithardt G, Camm AJ, Caso V, Nielsen JC, De Melis M, De Potter T, Dichtl W, Diederichsen SZ, Dobrev D, Doll N, Duncker D, Dworatzek E, Eckardt L, Eisert C, Fabritz L, Farkowski M, Filgueiras-Rama D, Goette A, Guasch E, Hack G, Hatem S, Haeusler KG, Healey JS, Heidbuechel H, Hijazi Z, Hofmeister LH, Hove-Madsen L, Huebner T, Kääb S, Kotecha D, Malaczynska-Rajpold K, Merino JL, Metzner A, Mont L, Ng GA, Oeff M, Parwani AS, Puererfellner H, Ravens U, Rienstra M, Sanders P, Scherr D, Schnabel R, Schotten U, Sohns C, Steinbeck G, Steven D, Toennis T, Tzeis S, van Gelder IC, van Leerdam RH, Vernooy K, Wadhwa M, Wakili R, Willems S, Witt H, Zeemering S, Kirchhof P. Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference. Europace 2024; 26:euae070. [PMID: 38591838 PMCID: PMC11003300 DOI: 10.1093/europace/euae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/16/2024] [Indexed: 04/10/2024] Open
Abstract
AIMS Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). METHODS AND RESULTS Eighty-three international experts met in Münster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF. CONCLUSIONS Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF.
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Affiliation(s)
- Dominik Linz
- Department of Cardiology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jason G Andrade
- Division of Cardiology, Vancouver General Hospital, Vancouver, Canada
- Montreal Heart Institute, Montreal, Canada
| | - Elena Arbelo
- Institut Clínic Cardiovascular, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart—ERN GUARD-Heart
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Polyclinic of Modena, Modena, Italy
| | - Guenter Breithardt
- Department of Cardiovascular Medicine, University Hospital, Münster, Germany
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Wolfgang Dichtl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Dobromir Dobrev
- Institute of Pharmacology, Faculty of Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nicolas Doll
- Department of Cardiac Surgery, Schüchtermann-Klinik, Bad Rothenfelde, Germany
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Lars Eckardt
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Cardiology II—Electrophysiology, University Hospital Münster, Münster, Germany
| | | | - Larissa Fabritz
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- University Center of Cardiovascular Science, UHZ, UKE, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Michal Farkowski
- Department of Cardiology, Ministry of Interior and Administration, National Medical Institute, Warsaw, Poland
| | - David Filgueiras-Rama
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Novel Arrhythmogenic Mechanisms Program, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, C/ Profesor Martín Lagos, Madrid, Spain
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Cardiology and Intensive Care Medicine, St Vincenz-Hospital Paderborn, Paderborn, Germany
| | - Eduard Guasch
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Clinic Barcelona, University of Barcelona, Barcelona, Spain
| | - Guido Hack
- Bristol-Myers Squibb GmbH & Co. KGaA, Munich, Germany
| | | | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | - Jeff S Healey
- Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Hein Heidbuechel
- Antwerp University Hospital, Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium
| | - Ziad Hijazi
- Antwerp University Hospital, Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Leif Hove-Madsen
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Biomedical Research Institute Barcelona (IIBB-CSIC), Barcelona, Spain
- IR Sant Pau, Hospital de Sant Pau, Barcelona, Spain
| | | | - Stefan Kääb
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart—ERN GUARD-Heart
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Katarzyna Malaczynska-Rajpold
- Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
- Royal Brompton Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - José Luis Merino
- La Paz University Hospital, IdiPaz, Autonomous University of Madrid, Madrid, Spain
| | - Andreas Metzner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Lluís Mont
- Institut Clínic Cardiovascular, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ghulam Andre Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Michael Oeff
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Cardiology Department, Medizinische Hochschule Brandenburg, Brandenburg/Havel, Germany
| | - Abdul Shokor Parwani
- Department of Cardiology, Deutsches Herzzentrum der Charité (CVK), Berlin, Germany
| | | | - Ursula Ravens
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Institute of Experimental Cardiovascular Medicine, University Clinic Freiburg, Freiburg, Germany
| | - Michiel Rienstra
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Daniel Scherr
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Renate Schnabel
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Ulrich Schotten
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Departments of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Christian Sohns
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Klinik für Elektrophysiologie—Rhythmologie, Bad Oeynhausen, Germany
| | - Gerhard Steinbeck
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Center for Cardiology at Clinic Starnberg, Starnberg, Germany
| | - Daniel Steven
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Heart Center, Department of Electrophysiology, University Hospital Cologne, Cologne, Germany
| | - Tobias Toennis
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | | | - Isabelle C van Gelder
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Manish Wadhwa
- Medical Office, Philips Ambulatory Monitoring and Diagnostics, San Diego, CA, USA
| | - Reza Wakili
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Medicine and Cardiology, Goethe University, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany
| | - Stephan Willems
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Asklepios Hospital St. Georg, Department of Cardiology and Internal Care Medicine, Faculty of Medicine, Semmelweis University Campus, Hamburg, Germany
| | | | - Stef Zeemering
- Departments of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
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Lim WH, Lee SR, Choi EK, Lee SW, Han KD, Oh S, Lip GYH. Combination of early rhythm control and healthy lifestyle on the risk of stroke in elderly patients with new-onset atrial fibrillation: a nationwide population-based cohort study. Front Cardiovasc Med 2024; 11:1346414. [PMID: 38426116 PMCID: PMC10902049 DOI: 10.3389/fcvm.2024.1346414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/07/2024] [Indexed: 03/02/2024] Open
Abstract
Background The impact of early rhythm control (ERC) combined with healthy lifestyle (HLS) on the risk of ischemic stroke in elderly patients with atrial fibrillation (AF) remains unaddressed. Objective To evaluate the impact of combined ERC and HLS on the risk of stroke in elderly patients with new-onset AF. Methods Using the Korean National Health Insurance Service database, we included patients aged ≥75 years with new-onset AF from January 2009 to December 2016 (n = 41,315). Patients who received rhythm control therapy within 2 years of AF diagnosis were defined as the ERC group. Non-smoking, non-to-mild alcohol consumption (<105 g/week), and regular exercise were defined as HLS. Subjects were categorized into four groups: group 1 (without ERC and HLS, n = 25,093), 2 (HLS alone, n = 8,351), 3 (ERC alone, n = 5,565), and 4 (both ERC and HLS, n = 2,306). We assessed the incidence of ischemic stroke as the primary outcome, along with admissions for heart failure, all-cause death, and the composite of ischemic stroke, admission for heart failure, and all-cause death. Results Median follow-up duration of the study cohort was 3.4 years. After adjusting for multiple variables, groups 2 and 3 were associated with a lower stroke risk (adjusted hazard ratio [aHR]: 95% confidence interval [CI]: 0.867, 0.794-0.948 and 0.713, 0.637-0.798, respectively) than that of group 1. Compared to Group 1, group 4 showed the lowest stroke risk (aHR: 0.694, 95% CI: 0.586-0.822) among all groups, followed by group 3 (0.713, 0.637-0.798) and group 2 (0.857, 0.794-0.948), respectively. Group 4 was associated with the lowest risk of all-cause death (aHR: 0.680, 95% CI: 0.613-0.754) and the composite outcome (aHR: 0.708, 95% CI: 0.649-0.772). Conclusion ERC and HLS were associated with a lower risk of ischemic stroke in elderly patients with new-onset AF. Concurrently implementing ERC and maintaining HLS was associated with the lowest risk of death and the composite outcome, with a modest synergistic effect on stroke prevention.
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Affiliation(s)
- Woo-Hyun Lim
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung-Woo Lee
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung-Do Han
- Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y. H. Lip
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Chest and Heart Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Elsheikh S, Hill A, Irving G, Lip GYH, Abdul-Rahim AH. Atrial fibrillation and stroke: State-of-the-art and future directions. Curr Probl Cardiol 2024; 49:102181. [PMID: 37913929 DOI: 10.1016/j.cpcardiol.2023.102181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/03/2023]
Abstract
Atrial fibrillation (AF) and stroke remain a major cause of morbidity and mortality. The two conditions shared common co-morbidities and risk factors. AF-related strokes are associated with worse clinical outcomes and higher mortality compared to non-AF-related. Early detection of AF is vital for prevention. While various scores have been developed to predict AF in such a high-risk group, they are yet to incorporated into clinical guidelines. Novel markers and predictors of AF including coronary and intracranial arterial calcification have also been studied. There are also ongoing debates on the management of acute stroke in patients with AF, and those who experienced breakthrough stroke while on oral anticoagulants. We provided an overview of the complex interplay between AF and stroke, as well as the treatment and secondary prevention of stroke in AF. We also comprehensively discussed the current evidence and the ongoing conundrums, and highlighted the future directions on the topic.
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Affiliation(s)
- Sandra Elsheikh
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK.
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
| | - Greg Irving
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Health Research Institute, Edge Hill University Faculty of Health and Social Care, Ormskirk, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
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Goetze M, Knauf T, Ebelt H. Relationship between Pharmacological Treatment Strategy and Cognitive Function in Geriatric Patients with Atrial Fibrillation. J Clin Med 2023; 12:7724. [PMID: 38137793 PMCID: PMC10743707 DOI: 10.3390/jcm12247724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Background and question: Atrial fibrillation (AF) is the most common cardiac arrhythmia in the total population. The aim of this study is to determine how geriatric patients with AF are treated in terms of rhythm or rate control and whether a relationship between the type of treatment and Mini Mental Status (MMS) can be identified. METHODS In this monocentric, prospective, observational study, data including chronic medication as well as demographic parameters were collected from all patients in a geriatric department between April 2021 and April 2022. A 12-lead ECG as well as the Mini Mental Status were recorded for all patients as part of the admission routine, and a 24 h ECG was performed in selected patients on the basis of clinical indication. RESULTS At baseline, 715 out of 1914 patients (37.4%) had a known history of AF. Of these patients, 43 patients (6%) were on rhythm control therapy (RHY) and 672 (94%) were on rate control therapy (RATE). No difference in respect to MMS could be detected between RHY and RATE. However, linear regression analyses showed that age, HASBLED score, creatinine serum level, and an existing antiplatelet medication were associated with a negative influence on MMS, whereas oral anticoagulation (OAC) was associated with improved MMS, respectively (p < 0.05 for all). CONCLUSION The vast majority of geriatric patients with AF are treated with a rate control strategy. Oral anticoagulation is associated with better results in MMS, whereas patients who are treated with antiplatelet medication show worse results in MMS instead.
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Affiliation(s)
- Markus Goetze
- Department for Geriatrics, St. Elisabeth Hospital, Bahnhofstrasse 19, 99976 Lengenfeld unterm Stein, Germany;
| | - Tim Knauf
- Department of Medicine II, Catholic Hospital “St. Johann Nepomuk”, Haarbergstr. 72, 99097 Erfurt, Germany
| | - Henning Ebelt
- Department of Medicine II, Catholic Hospital “St. Johann Nepomuk”, Haarbergstr. 72, 99097 Erfurt, Germany
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Tseng AS, Desimone CV, Kowlgi GN. Antiarrhythmic drugs for atrial fibrillation in the outpatient setting. Minerva Med 2023; 114:839-849. [PMID: 37338231 DOI: 10.23736/s0026-4806.23.08524-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
With burgeoning evidence for early rhythm control in patients with atrial fibrillation (AF), the management of AF in the outpatient setting has become more challenging. The primary care clinician often serves as the frontline in the pharmacologic management of AF. Because of drug interactions and the risk of proarrhythmia, many clinicians remain hesitant about the initiation and chronic management of antiarrhythmic drug prescriptions. However, with the likely increased use of antiarrhythmics for early rhythm control, understanding and familiarity with these medications have likewise become more important, especially since patients with AF probably have other non-cardiac medical conditions that can impact their antiarrhythmic therapy. In this comprehensive review, we provide informative, high-yield cases and edifying references that will help primary care providers become comfortable handling various clinical scenarios.
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Affiliation(s)
- Andrew S Tseng
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Gurukripa N Kowlgi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA -
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Knudsen Pope M, Hall TS, Virdone S, Atar D, John Camm A, Pieper KS, Jansky P, Haas S, Goto S, Panchenko E, Baron-Esquivias G, Angchaisuksiri P, Kakkar AK. Rhythm versus rate control in patients with newly diagnosed atrial fibrillation - Observations from the GARFIELD-AF registry. Int J Cardiol Heart Vasc 2023; 49:101302. [PMID: 38020059 PMCID: PMC10656718 DOI: 10.1016/j.ijcha.2023.101302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023]
Abstract
Background Investigate real-world outcomes of early rhythm versus rate control in patients with recent onset atrial fibrillation. Methods The Global Anticoagulant Registry in the FIELD-AF (GARFIELD-AF) is an international multi-centre, non-interventional prospective registry of newly diagnosed (≤6 weeks' duration) atrial fibrillation patients at risk for stroke. Patients were stratified according to treatment initiated at baseline (≤48 days post enrolment), and outcome risks evaluated by overlap propensity weighted Cox proportional-hazards models. Results Of 45,382 non-permanent atrial fibrillation patients, 23,858 (52.6 %) received rhythm control and 21,524 (47.4 %) rate control. Rhythm-controlled patients had lower median age (68.0 [Q1;Q3: 60.0;76.0] versus 73.0 [65.0;79.0]), fewer histories of stroke/transient ischemic attack/systemic embolism (9.4 % versus 13.0 %), and lower expected probabilities of death (median GARFIELD-AF death score 4.0 [2.3;7.5] versus 5.1 [2.8;9.2]). The two groups had the same median CHA2DS2-VASc scores (3.0 [2.0;4.0]) and similar proportions of anticoagulated patients (rhythm control: 66.0 %, rate control: 65.5 %). The propensity-score-weighted hazard ratios of rhythm vs rate control (reference) were 0.85 (95 % CI: 0.79-0.92, p-value < 0.0001) for all-cause mortality, 0.84 (0.72-0.97, p-value 0.020) for non-haemorrhagic stroke/systemic embolism and 0.90 (0.78-1.04, p-value 0.164) for major bleeding. Conclusion Rhythm control strategy was initiated in about half of the patients with newly diagnosed non-valvular non-permanent atrial fibrillation. After balancing confounders, significantly lower risks of all-cause mortality and non-haemorrhagic stroke were observed in patients who received early rhythm control.
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Affiliation(s)
| | - Trygve S. Hall
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Saverio Virdone
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - A. John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George’s University of London, London, the United Kingdom of Great Britain and Northern Ireland
| | - Karen S Pieper
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
| | - Petr Jansky
- Department of Cardiovascular Surgery, Motol University Hospital, Prague, Czech Republic
| | - Sylvia Haas
- Sylvia Haas: Formerly Department of Medicine, Technical University of Munich, Munich, Germany
| | | | - Elizaveta Panchenko
- National Medical Research Center of Cardiology of Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Gonzalo Baron-Esquivias
- Servicio de Cardiología y Cirugía Cardíaca, Hospital Universitario Virgen del Rocío., Universidad de Sevilla., Sevilla. Departamento Cardiovascular, Instituto de Biotecnología de Sevilla (IBIS), Spain
| | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
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Morin DP. Early rhythm control for atrial fibrillation: looking cost-effective, at least from one direction. Europace 2023; 25:euad085. [PMID: 36994788 PMCID: PMC10228532 DOI: 10.1093/europace/euad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Affiliation(s)
- Daniel P Morin
- Department of Cardiology, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA
- Department of Cardiology, University of Queensland Ochsner Clinical School, 1514 Jefferson Highway, New Orleans, LA 70121, USA
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Gottschalk S, Kany S, König HH, Crijns HJGM, Vardas P, Camm AJ, Wegscheider K, Metzner A, Rillig A, Kirchhof P, Dams J. Cost-effectiveness of early rhythm control vs. usual care in atrial fibrillation care: an analysis based on data from the EAST-AFNET 4 trial. Europace 2023; 25:euad051. [PMID: 36966734 PMCID: PMC10227663 DOI: 10.1093/europace/euad051] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/30/2023] [Indexed: 03/29/2023] Open
Abstract
AIMS The randomized, controlled EAST-AFNET 4 trial showed that early rhythm control (ERC) reduces the rate of a composite primary outcome (cardiovascular death, stroke, or hospitalization for worsening heart failure or acute coronary syndrome) by ∼20%. The current study examined the cost-effectiveness of ERC compared to usual care. METHODS AND RESULTS This within-trial cost-effectiveness analysis was based on data from the German subsample of the EAST-AFNET 4 trial (n = 1664/2789 patients). Over a 6-year time horizon and from a healthcare payer's perspective, ERC was compared to usual care regarding costs (hospitalization and medication) and effects (time to primary outcome; years survived). Incremental cost-effectiveness ratios (ICERs) were calculated. Cost-effectiveness acceptability curves were constructed to visualize uncertainty. Early rhythm control was associated with higher costs [+€1924, 95% CI (-€399, €4246)], resulting in ICERs of €10 638 per additional year without a primary outcome and €22 536 per life year gained. The probability of ERC being cost-effective compared to usual care was ≥95% or ≥80% at a willingness-to-pay value of ≥€55 000 per additional year without a primary outcome or life year gained, respectively. CONCLUSION From a German healthcare payer's perspective, health benefits of ERC may come at reasonable costs as indicated by the ICER point estimates. Taking statistical uncertainty into account, cost-effectiveness of ERC is highly probable at a willingness-to-pay value of ≥€55 000 per additional life year or year without a primary outcome. Future studies examining the cost-effectiveness of ERC in other countries, subgroups with higher benefit from rhythm control therapy, or cost-effectiveness of different modes of ERC are warranted.
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Affiliation(s)
- Sophie Gottschalk
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Martinistraße 52 Building W37, 20246 Hamburg, Germany
| | - Shinwan Kany
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Martinistraße 52 Building W37, 20246 Hamburg, Germany
| | - Harry JGM Crijns
- Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Universiteitssingel 50, 6200 MD, Maastricht, The Netherlands
| | - Panos Vardas
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, 29 square de Meeus, B-1000 Brussels, BELGIUM
| | - A John Camm
- Molecular & Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Christoph-Probst-Weg 1, 20246 Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany
| | - Andreas Rillig
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Judith Dams
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Martinistraße 52 Building W37, 20246 Hamburg, Germany
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Dickow J, Kany S, Cardoso VR, Ellinor PT, Gkoutos GV, Van Houten HK, Kirchhof P, Metzner A, Noseworthy PA, Yao X, Rillig A. Outcomes of Early Rhythm Control Therapy in Patients With Atrial Fibrillation and a High Comorbidity Burden in Large Real-World Cohorts. Circ Arrhythm Electrophysiol 2023; 16:e011585. [PMID: 36942567 PMCID: PMC10205477 DOI: 10.1161/circep.122.011585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/24/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND A recent subanalysis of the EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) suggests a stronger benefit of early rhythm control (ERC) in patients with atrial fibrillation and a high comorbidity burden when compared to patients with a lower comorbidity burden. METHODS We identified 109 739 patients with newly diagnosed atrial fibrillation in a large United States deidentified administrative claims database (OptumLabs) and 11 625 patients in the population-based UKB (UK Biobank). ERC was defined as atrial fibrillation ablation or antiarrhythmic drug therapy within the first year after atrial fibrillation diagnosis. Patients were classified as (1) ERC and high comorbidity burden (CHA2DS2-VASc score ≥4); (2) ERC and lower comorbidity burden (CHA2DS2-VASc score 2-3); (3) no ERC and high comorbidity burden; and (4) no ERC and lower comorbidity burden. Patients without an elevated comorbidity burden (CHA2DS2-VASc score 0-1) were excluded. Propensity score overlap weighting and cox proportional hazards regression were used to balance patients and compare groups for the primary composite outcome of all-cause mortality, stroke, or hospitalization with the diagnoses heart failure or myocardial infarction as well as for a primary composite safety outcome of death, stroke, and serious adverse events related to ERC. RESULTS In both cohorts, ERC was associated with a reduced risk for the primary composite outcome in patients with a high comorbidity burden (OptumLabs: hazard ratio, 0.83 [95% CI 0.72-0.95]; P=0.006; UKB: hazard ratio, 0.77 [95% CI, 0.63-0.94]; P=0.009). In patients with a lower comorbidity burden, the difference in outcomes was not significant (OptumLabs: hazard ratio, 0.92 [95% CI, 0.54-1.57]; P=0.767; UKB: hazard ratio, 0.94 [95% CI, 0.83-1.06]; P=0.310). The comorbidity burden interacted with ERC in the UKB (interaction- P=0.027) but not in OptumLabs (interaction-P=0.720). ERC was not associated with an increased risk for the primary safety outcome. CONCLUSIONS ERC is safe and may be more favorable in a population-based sample of patients with high a comorbidity burden (CHA2DS2-VASc score ≥4).
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Affiliation(s)
- Jannis Dickow
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Shinwan Kany
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Cardiovascular Disease Initiative, The Broad Inst of MIT & Harvard, Cambridge, MA
| | - Victor Roth Cardoso
- Institute of Cardiovascular Sciences
- Institute of Cancer & Genomic Sciences, Univ of Birmingham
- Health Data Rsrch UK, Midlands Site, Birmingham, United Kingdom
| | - Patrick T. Ellinor
- Cardiovascular Disease Initiative, The Broad Inst of MIT & Harvard, Cambridge, MA
- Cardiovascular Rsrch Ctr, Massachusetts General Hospital, Boston, MA
| | - Georgios V. Gkoutos
- Institute of Cardiovascular Sciences
- Institute of Cancer & Genomic Sciences, Univ of Birmingham
- Health Data Rsrch UK, Midlands Site, Birmingham, United Kingdom
| | - Holly K. Van Houten
- OptumLabs, Eden Prairie
- Robert D. & Patricia E. Kern Ctr for the Science of Health Care Delivery
| | - Paulus Kirchhof
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Institute of Cardiovascular Sciences
| | - Andreas Metzner
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Peter A. Noseworthy
- Robert D. & Patricia E. Kern Ctr for the Science of Health Care Delivery
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Xiaoxi Yao
- Robert D. & Patricia E. Kern Ctr for the Science of Health Care Delivery
- Dept of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Andreas Rillig
- Dept of Cardiology, Univ Heart & Vascular Center Hamburg, Univ Hospital Hamburg Eppendorf, Hamburg
- DZHK (German Ctr for Cardiovascular Rsrch), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
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Jensen M, Suling A, Metzner A, Schnabel RB, Borof K, Goette A, Haeusler KG, Zapf A, Wegscheider K, Fabritz L, Diener HC, Thomalla G, Kirchhof P. Early rhythm-control therapy for atrial fibrillation in patients with a history of stroke: a subgroup analysis of the EAST-AFNET 4 trial. Lancet Neurol 2023; 22:45-54. [PMID: 36517170 DOI: 10.1016/s1474-4422(22)00436-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with atrial fibrillation and a history of stroke are at high risk of recurrent stroke and cardiovascular complications. In the EAST-AFNET 4 trial we showed that a systematic strategy of early rhythm control was associated with a lower risk of cardiovascular outcomes than usual care in patients with atrial fibrillation diagnosed in the past 12 months. In this pre-specified subgroup analysis we aimed to assess whether a strategy of early rhythm control is safe and can prevent adverse cardiovascular outcomes compared with usual care in such patients. METHODS EAST-AFNET 4 was a randomised, open-label trial with blinded-outcome assessment done at 135 hospitals and secondary care practices in 11 European countries. Adults with early atrial fibrillation (ie, diagnosed ≤12 months before enrolment) were randomly assigned (1:1) to either early rhythm control or usual care, with stratification according to site and variable block lengths used for concealment. The first primary outcome was time to first occurrence of the composite of cardiovascular death, ischaemic or haemorrhagic stroke, or hospital admission with worsening of heart failure or acute coronary syndrome. The second primary outcome was the number of nights spent in hospital in 1 year. The primary safety outcome was the composite of any death, stroke, or serious adverse events related to rhythm-control therapy. Here we present the results of these outcomes in patients with a history of stroke. Analyses were done in the intention-to-treat population. EAST-AFNET 4 is registered with ClinicalTrials.gov (NCT01288352), EudraCT (2010-021258-20), and ISRCTN (ISRCTN04708680). FINDINGS Between July 28, 2011, and Dec 30, 2016, 2789 patients were randomly assigned in the EAST-AFNET 4 trial to either early rhythm control (n=1395) or usual care (n=1394). Of these patients, five had no information on history of stroke and were excluded from this subgroup analysis. 217 (8%) patients had a history of stroke, of whom 110 were assigned to early rhythm control and 107 to usual care. The median age of participants with a history of stroke was 72·0 years (IQR 66·0-76·0). 95 (44%) participants were female and 122 (56%) were male. During a median follow-up of 4·7 years (3·5-6·4) for patients with a history of stroke, a first primary outcome event occurred in 18 (16%) of 110 patients in the early rhythm-control group (3·7 per 100 person-years) and 33 (31%) of 107 in the usual care group (7·4 per 100 person-years; hazard ratio [HR] 0·52, 95% CI 0·29-0·93). The mean number of nights spent in hospital per year was 5·1 (SD 13·2) for patients with a history of stroke assigned to early rhythm control and 6·6 (10·1) for those assigned to usual care (incidence rate ratio 0·87, 95% CI 0·55-1·38). Among patients with a history of stroke, primary safety events occurred in 17 (15%) patients in the early rhythm-control group versus 30 (28%) in the usual care group. INTERPRETATION In this prespecified subgroup analysis in patients with recently diagnosed atrial fibrillation and a history of stroke, the effects of early rhythm control were consistent with the findings of the primary analysis. As the evidence from this subgroup analysis is considered supportive and exploratory, further research is needed to confirm the safety and efficacy of this approach in patients with a history of stroke. FUNDING German Ministry of Education and Research, German Center for Cardiovascular Research (DZHK), Atrial Fibrillation Network (AFNET), European Heart Rhythm Association, St Jude Medical-Abbott, Sanofi, and the German Heart Foundation.
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Affiliation(s)
- Märit Jensen
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
| | - Anna Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Goette
- St Vincenz Hospital Paderborn, Paderborn, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation Network, Münster, Germany; Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany
| | - Larissa Fabritz
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; University Center of Cardiovascular Sciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Atrial Fibrillation Network, Münster, Germany; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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12
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Kany S, Cardoso VR, Bravo L, Williams JA, Schnabel R, Fabritz L, Gkoutos GV, Kirchhof P. Eligibility for early rhythm control in patients with atrial fibrillation in the UK Biobank. Heart 2022; 108:1873-1880. [PMID: 35835543 PMCID: PMC9664114 DOI: 10.1136/heartjnl-2022-321196] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/10/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE The Early Treatment of Atrial Fibrillation for Stroke Prevention (EAST-AFNET4) trial showed a clinical benefit of early rhythm-control therapy in patients with recently diagnosed atrial fibrillation (AF). The generalisability of the results in the general population is not known. METHODS Participants in the population-based UK Biobank were assessed for eligibility based on the EAST-AFNET4 inclusion/exclusion criteria. Treatment of all eligible participants was classified as early rhythm-control (antiarrhythmic drug therapy or AF ablation) or usual care. To assess treatment effects, primary care data and Hospital Episode Statistics were merged with UK Biobank data.Efficacy and safety outcomes were compared between groups in the entire cohort and in a propensity-matched data set. RESULTS AF was present in 35 526/502 493 (7.1%) participants, including 8340 (988 with AF <1 year) with AF at enrolment and 27 186 with incident AF during follow-up. Most participants (22 003/27 186; 80.9%) with incident AF were eligible for early rhythm-control.Eligible participants were older (70 years vs 63 years) and more likely to be female (42% vs 21%) compared with ineligible patients. Of 9004 participants with full primary care data, 874 (9.02%) received early rhythm-control. Safety outcomes were not different between patients receiving early rhythm-control and controls. The primary outcome of EAST-AFNET 4, a composite of cardiovascular death, stroke/transient ischaemic attack and hospitalisation for heart failure or acute coronary syndrome occurred less often in participants receiving early rhythm-control compared with controls in the entire cohort (HR 0.82, 95% CI 0.71 to 0.94, p=0.005). In the propensity-score matched analysis, early rhythm-control did not significantly decrease of the primary outcome compared with usual care (HR 0.87, 95% CI 0.72 to 1.04, p=0.124). CONCLUSION Around 80% of participants diagnosed with AF in the UK population are eligible for early rhythm-control. Early rhythm-control therapy was safe in routine care.
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Affiliation(s)
- Shinwan Kany
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,Partner site Hamburg/Kiel/Lübeck, German Center for Cardiovascular Sciences (DZHK), Hamburg, Germany
| | - Victor Roth Cardoso
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Midlands Site, Health Data Research UK, Birmingham, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Laura Bravo
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Midlands Site, Health Data Research UK, Birmingham, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - John A Williams
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Midlands Site, Health Data Research UK, Birmingham, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Renate Schnabel
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Partner site Hamburg/Kiel/Lübeck, German Center for Cardiovascular Sciences (DZHK), Hamburg, Germany
| | - Larissa Fabritz
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Partner site Hamburg/Kiel/Lübeck, German Center for Cardiovascular Sciences (DZHK), Hamburg, Germany.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Georgios V Gkoutos
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Midlands Site, Health Data Research UK, Birmingham, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Paulus Kirchhof
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany .,Partner site Hamburg/Kiel/Lübeck, German Center for Cardiovascular Sciences (DZHK), Hamburg, Germany.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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13
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Zhu W, Wu Z, Dong Y, Lip GYH, Liu C. Effectiveness of early rhythm control in improving clinical outcomes in patients with atrial fibrillation: a systematic review and meta-analysis. BMC Med 2022; 20:340. [PMID: 36224587 PMCID: PMC9558983 DOI: 10.1186/s12916-022-02545-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 09/01/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Current guidelines recommend rhythm control for improving symptoms and quality of life in symptomatic patients with atrial fibrillation (AF). However, the long-term prognostic outcomes of rhythm control compared with rate control are still inconclusive. In this meta-analysis, we aimed to assess the effects of early rhythm control compared with rate control on clinical outcomes in newly diagnosed AF patients. METHODS We systematically searched the PubMed and Embase databases up to August 2022 for randomized and observational studies reporting the associations of early rhythm control (defined as within 12 months of AF diagnosis) with effectiveness outcomes. The primary outcome was a composite of death, stroke, admission to hospital for heart failure (HF), or acute coronary syndrome (ACS). Hazard ratios (HRs) and 95% confidence intervals (CIs) from each study were pooled using a random-effects model, complemented with an inverse variance heterogeneity or quality effects model. RESULTS A total of 8 studies involving 447,202 AF patients were included, and 23.5% of participants underwent an early rhythm-control therapy. In the pooled analysis using the random-effects model, compared with rate control, the early rhythm-control strategy was significantly associated with reductions in the primary composite outcome (HR = 0.88, 95% CI: 0.86-0.89) and secondary outcomes, including stroke or systemic embolism (HR = 0.78, 95% CI: 0.71-0.85), ischemic stroke (HR = 0.81, 95% CI: 0.69-0.94), cardiovascular death (HR = 0.83, 95% CI: 0.70-0.99), HF hospitalization (HR = 0.90, 95% CI: 0.88-0.92), and ACS (HR = 0.86, 95% CI: 0.76-0.98). Reanalyses using the inverse variance heterogeneity or quality effects model yielded similar results. CONCLUSIONS Our current meta-analysis suggested that early initiation of rhythm control treatment was associated with improved adverse effectiveness outcomes in patients who had been diagnosed with AF within 1 year. REGISTRATION The study protocol was registered to PROSPERO (CRD42021295405).
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Affiliation(s)
- Wengen Zhu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China. .,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, People's Republic of China. .,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China.
| | - Zexuan Wu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, People's Republic of China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Yugang Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, People's Republic of China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Sciences, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK. .,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Chen Liu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China. .,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, People's Republic of China. .,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China.
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14
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Eckardt L, Sehner S, Suling A, Borof K, Breithardt G, Crijns HJGM, Goette A, Wegscheider K, Zapf A, Camm AJ, Metzner A, Kirchhof P. Attaining sinus rhythm mediates improved outcome with early rhythm control therapy of atrial fibrillation: the EAST - AFNET 4 trial. Eur Heart J 2022; 43:4127-4144. [PMID: 36036648 PMCID: PMC9584752 DOI: 10.1093/eurheartj/ehac471] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/22/2022] Open
Abstract
Aims A strategy of systematic, early rhythm control (ERC) improves cardiovascular outcomes in patients with atrial fibrillation (AF). It is not known how this outcome-reducing effect is mediated. Methods and results Using the Early treatment of Atrial Fibrillation for Stroke prevention Trial (EAST—AFNET 4) data set, potential mediators of the effect of ERC were identified in the total study population at 12-month follow up and further interrogated by use of a four-way decomposition of the treatment effect in an exponential model predicting future primary outcome events. Fourteen potential mediators of ERC were identified at the 12-month visit. Of these, sinus rhythm at 12 months explained 81% of the treatment effect of ERC compared with usual care during the remainder of follow up (4.1 years). In patients not in sinus rhythm at 12 months, ERC did not reduce future cardiovascular outcomes (hazard ratio 0.94, 95% confidence interval 0.65–1.67). Inclusion of AF recurrence in the model only explained 31% of the treatment effect, and inclusion of systolic blood pressure at 12 months only 10%. There was no difference in outcomes in patients who underwent AF ablation compared with those who did not undergo AF ablation. Conclusion The effectiveness of early rhythm control is mediated by the presence of sinus rhythm at 12 months in the EAST-AFNET 4 trial. Clinicians implementing ERC should aim for rapid and sustained restoration of sinus rhythm in patients with recently diagnosed AF and cardiovascular comorbidities.
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Affiliation(s)
- L Eckardt
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Germany.,2Atrial Fibrillation Network (AFNET), Münster, Germany
| | - S Sehner
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - A Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - K Borof
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
| | - G Breithardt
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Germany.,2Atrial Fibrillation Network (AFNET), Münster, Germany
| | - H J G M Crijns
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Netherlands
| | - A Goette
- 2Atrial Fibrillation Network (AFNET), Münster, Germany.,Department of Cardiology, Vincenz-Krankenhaus Paderborn, Germany
| | - K Wegscheider
- 2Atrial Fibrillation Network (AFNET), Münster, Germany.,Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - A Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - A J Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George's University of London, UK
| | - A Metzner
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - P Kirchhof
- 2Atrial Fibrillation Network (AFNET), Münster, Germany.,Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Berlin, Germany.,Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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