Rethinking Rhythm Control in AF: Sooner Rather than Later?

One of the several noteworthy trials presented at the virtual ESC Congress was the EAST-AFNET 4NET 4 trial, which was published concurrently in the New England Journal of Medicine.  EAST-AFNET 4 demonstrated the superiority of a rhythm-control strategy over usual care (rate control in the majority of cases) in improving 5-year CV outcomes in patients with a recent AFib diagnosis and other CV conditions.

I had a chance to ask a few questions of Dr. Deepak Bhatt regarding his insights on the implications of the EAST-AFNET 4 trial results.

Were you surprised at the results of the EAST-AFNET 4 trial? Any noteworthy limitations, or caveats regarding the results?

DLB: Surprised at the results? Yes and no. I was a bit surprised, as the results were different than AFFIRM and RACE. This may have been the very early randomization – within a median of 36 days of diagnosis.

I wasn’t surprised because deep down, this is what I have always believed (as is the case with many physicians).

One limitation is that highly symptomatic patients would have been excluded, of course. In those patients, rhythm control is typically instituted already.

Do you think the cardiology community will readily integrate the information from this trial into practice? Do you think that cardiologists will now evaluate patients with new-onset AFib now and if no contraindications, promptly consider them for class 1-C agents (like flecainide and propafenone) in an effort toward early rhythm control?  And might there also be referrals to cardiac electrophysiologists earlier in the treatment paradigm to evaluate for possible ablation?

DLB: I think physicians tend to embrace findings when the data are consistent with what they already believe. So, for many cardiologists and cardiac electrophysiologists, I think they will be more likely now to implement early rhythm control with medications and with ablation. I believe this will lead to more referrals to cardiac electrophysiology.

Noting that the patients in EAST-AFNET 4 were treated very early after the diagnosis of AFib was made (mean 36 days), might this change recommendations about screening for AFib?

DLB: I don’t know if guideline recommendations will change or not, but the reality is that patients will increasingly be screening themselves for atrial fibrillation with smartphones and smartwatches – regardless of whether physicians support it or not. So, we will be seeing a lot more evaluations for suspected arrhythmias, including atrial fibrillation.

Management of atrial fibrillation in the current era is undoubtedly seeing a paradigm shift. In the 2018 AHA scientific statement, “Atrial Fibrillation Burden: Moving Beyond Atrial Fibrillation as a Binary Entity,” the writers also noted the evolution of these monitoring technologies Dr. Bhatt references altering the landscape of long-term AF monitoring. They noted the continuous monitoring capability of contemporary cardiac implantable electronic devices (CIEDs), including dual-chamber pacemakers and ICDs, and the now common incidental detection of subclinical AF during interrogation of these devices. The proliferation of consumer mobile technology like smartwatches which can record a 1 lead rhythm strip, and newer consumer ECG devices which can record up to a 6-lead EKG will undoubtedly play a role in earlier detection of AF, so these trial results are timely.

Thank you to Dr. Bhatt for both his valuable insights into the EAST-AFNET 4 trial and its results, and well as his thoughts on the implications of this new information on real-world clinical practice.