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The role of timing in treatment of atrial fibrillation: An AFFIRM substudy

Published:December 28, 2020DOI:https://doi.org/10.1016/j.hrthm.2020.12.025

      Background

      In contrast to historical trials, the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) suggests the superiority of early rhythm control over rate control in patients with recent-onset atrial fibrillation (AF). The relative contribution of timing vs improvement in AF therapeutics over time is unclear.

      Objective

      This study aimed to isolate the assessment of early intervention for AF from temporal changes in AF treatments through a secondary analysis of subjects from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study.

      Methods

      We compared rate and rhythm control treatments in AFFIRM subjects stratified by time from their diagnosis of AF. Time-to-event analysis was performed to compare all-cause mortality, cardiovascular hospitalizations, stroke, and number of hospitalization days.

      Results

      Of the 4060 AFFIRM subjects, 2526 subjects (62.2%) had their first episode of AF within 6 months of study enrollment. Participants with “new” AF had a decreased risk of all-cause mortality (P = .001) than did those with prior AF diagnoses. Individuals previously diagnosed with AF were similar in age and demographic characteristics, but had more medical comorbidities, including myocardial infarction (P = .006), diabetes mellitus (P = .002), smoking (P = .003), and hepatic or renal comorbidities (P = .008). There were no differences in mortality, cardiovascular hospitalizations, or stroke between rate and rhythm control strategies in either AF subgroup.

      Conclusion

      AFFIRM subjects diagnosed with AF within 6 months of study enrollment showed no difference in survival, cardiovascular hospitalization, or ischemic stroke between rate and rhythm control strategies. Superiority of rhythm control strategies reported by newer AF trials may be more attributable to the refinement of AF therapies and less related to the timing of intervention.

      Keywords

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      References

        • Mozaffarian D.
        • Benjamin E.J.
        • Go A.S.
        • et al.
        Heart disease and stroke statistics—2015 update: a report from the American Heart Association.
        Circulation. 2015; 131: e29-e322
        • Chugh S.S.
        • Havmoeller R.
        • Narayanan K.
        • et al.
        Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study.
        Circulation. 2014; 129: 837-847
        • Stewart S.
        • Hart C.L.
        • Hole D.J.
        • McMurray J.J.
        A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study.
        Am J Med. 2002; 113: 359-364
        • Benjamin E.J.
        • Wolf P.A.
        • D’Agostino R.B.
        • Silbershatz H.
        • Kannel W.B.
        • Levy D.
        Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.
        Circulation. 1998; 98: 946-952
        • Odutayo A.
        • Wong C.X.
        • Hsiao A.J.
        • Hopewell S.
        • Altman D.G.
        • Emdin C.A.
        Atrial fibrillation and risks of cardiovascular disease, renal disease, and death: systematic review and meta-analysis.
        BMJ. 2016; 354: i4482
        • Go A.S.
        • Hylek E.M.
        • Phillips K.A.
        • et al.
        Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study.
        JAMA. 2001; 285: 2370-2375
        • Wyse D.G.
        • Waldo A.L.
        • DiMarco J.P.
        • et al.
        A comparison of rate control and rhythm control in patients with atrial fibrillation.
        N Engl J Med. 2002; 347: 1825-1833
        • Calkins H.
        • Hindricks G.
        • Cappato R.
        • et al.
        2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.
        Europace. 2018; 20: e1-e160
        • Hindricks G.
        • Potpara T.
        • Dagres N.
        • et al.
        2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS).
        Eur Heart J. 2021; 42: 373-498
        • Sethi N.J.
        • Feinberg J.
        • Nielsen E.E.
        • Safi S.
        • Gluud C.
        • Jakobsen J.C.
        The effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter: a systematic review with meta-analysis and Trial Sequential Analysis.
        PLoS One. 2017; 12e0186856
        • Hunter R.J.
        • Berriman T.J.
        • Diab I.
        • et al.
        A randomized controlled trial of catheter ablation versus medical treatment of atrial fibrillation in heart failure (the CAMTAF trial).
        Circ Arrhythm Electrophysiol. 2014; 7: 31-38
        • Prabhu S.
        • Taylor A.J.
        • Costello B.T.
        • et al.
        Catheter ablation versus medical rate control in atrial fibrillation and systolic dysfunction: the CAMERA-MRI study.
        J Am Coll Cardiol. 2017; 70: 1949-1961
        • Marrouche N.F.
        • Brachmann J.
        • Andresen D.
        • et al.
        Catheter ablation for atrial fibrillation with heart failure.
        N Engl J Med. 2018; 378: 417-427
        • Kirchhof P.
        • Camm A.J.
        • Goette A.
        • et al.
        EAST-AFNET 4 Trial Investigators. Early rhythm-control therapy in patients with atrial fibrillation.
        N Engl J Med. 2020; 383: 1305-1316
        • Giffen C.A.
        • Wagner E.L.
        • Adams J.T.
        • et al.
        Providing researchers with online access to NHLBI biospecimen collections: the results of the first six years of the NHLBI BioLINCC program.
        PLoS One. 2017; 12e0178141
        • William A.D.
        • Kanbour M.
        • Callahan T.
        • et al.
        Assessing the accuracy of an automated atrial fibrillation detection algorithm using smartphone technology: the iREAD study.
        Heart Rhythm. 2018; 15: 1561-1565
        • Perez M.V.
        • Mahaffey K.W.
        • Hedlin H.
        • et al.
        Large-scale assessment of a smartwatch to identify atrial fibrillation.
        N Engl J Med. 2019; 381: 1909-1917

      Linked Article

      • Letter to the Editor—Clinical phenotypes in AF trials
        Heart RhythmVol. 18Issue 10
        • Preview
          Yang et al1 conducted a retrospective study of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. Their findings did not support the first primary Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) outcome.2 Clinical phenotypes of atrial fibrillation (AF) should be considered.
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