Benefit with early rhythm control in patients with recently diagnosed AF

EAST - AFNET 4: Effects of Early Rhythm Control Therapy in Patients with Atrial Fibrillation

News - Aug. 29, 2020

Presented at ESC congress 2020 by: Prof. Paulus Kirchhof, MD (Hamburg, Germany)

Introduction and methods

In the last years a lot of progress has been made in the management of patients with AF, the most common arrhythmia. Anticoagulation prevents most ischemic strokes and rate control renders many patients asymptomatic. Nonetheless, 5% of patients with AF suffer from CV death, stroke or hospitalization with acute HF or acute coronary syndrome.

The early treatment of AF for stroke prevention (EAST-AFNET 4) trial tested whether early rhythm control therapy improves outcomes compared to usual care in patients with early, recently diagnosed AF at risk of stroke.

EAST-AFNET 4 was a multicenter, investigator-initiated trial. A total of 2789 patients in the first year of AF diagnosis and at least two CV condition were enrolled in the trial between 2011 and 2016. Patients were randomized to early rhythm control or usual care (1:1). Both groups received anticoagulation, and treatment for CV conditions and rate control according to current guidelines. The early rhythm group (n=1,395) received antiarrhythmic drugs or catheter ablation (19.4% after 2 years) and the usual care group (n=1,394) were managed with rate control. Median follow-up was 5.1 years. First primary outcome was a composite of CV death, stroke, or hospitalization for HF or acute coronary syndrome. Second primary outcome was total nights spend in hospital.

Main results

  • The first primary outcome occurred 3.9% per year (249 patients) in the early rhythm group and 5% per year (316 patients) in the rate control group (HR 0.79, 95% CI: 0.67-0.94, P=0.005). The effect was consistent across all components of the first primary outcome.
  • No difference was observed between the treatment groups in the amount of nights spend in hospital.


Patients with early AF and CV conditions benefited from early rhythm control therapy, shown by a lower risk of CV events in the group of patients that received early rhythm control compared to those who received standard care.


In response to a question why early rhythm therapy outperformed usual care, Kirchhof answered that an intervention at an early stage reduces the risk for CV complications. When a patient stays longer in atrial fibrillation, the atria will be damaged, which makes it more difficult to return to a normal sinus rhythm.

-Our reporting is based on the information provided at the ESC congress –

The results were simultaneously published in the N Engl J Med Watch a video by prof. Kirchhof

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