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Rillig A, Eckardt L, Borof K, Camm AJ, Crijns HJGM, Goette A, Breithardt G, Lemoine MD, Metzner A, Rottner L, Schotten U, Vettorazzi E, Wegscheider K, Zapf A, Heidbuchel H, Willems S, Fabritz L, Schnabel RB, Magnussen C, Kirchhof P. Safety and efficacy of long-term Sodium Channel Blocker therapy for Early Rhythm Control: The EAST-AFNET 4 trial. Europace 2024:euae121. [PMID: 38702961 DOI: 10.1093/europace/euae121] [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: 01/15/2024] [Accepted: 03/13/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND AND AIMS Clinical concerns exist about the potential proarrhythmic effects of the sodium channel blockers flecainide and propafenone (SCB) in patients with cardiovascular disease. SCB were used to deliver early rhythm control (ERC) therapy in EAST-AFNET 4. METHODS We analysed the primary safety outcome (death, stroke, or serious adverse events related to rhythm-control therapy) and primary efficacy outcome (cardiovascular death, stroke and hospitalization for worsening of heart failure or acute coronary syndrome) during SCB-intake for ERC patients (n = 1395) in EAST-AFNET 4. The protocol discouraged flecainide and propafenone in patients with reduced left ventricular ejection fraction and suggested stopping therapy upon QRS prolongation >25% on therapy. RESULTS Flecainide or propafenone was given to 689 patients (age 69 (8) years; CHA2DS2-VASc 3.2 (1); 177 with heart failure; 41 with prior myocardial infarction, CABG or PCI; 26 with left ventricular hypertrophy >15 mm; median therapy duration 1,153 [237, 1,828] days). The primary efficacy outcome occurred less often in patients treated with SCB (3/100 (99/3,316) patient-years) than in patients who never received SCB (SCBnever 4.9/100 (150/3,083) patient-years, p < 0.001). There were numerically fewer primary safety outcomes in patients receiving SCB (2.9/100 (96/3,359) patient-years) than in SCBnever patients (4.2/100 (135/3,220) patient-years, adjusted p = 0.015). Sinus rhythm at 2 years was similar between groups (SCB 537/610 (88); SCBnever 472/579 (82)). CONCLUSION Long-term therapy with flecainide or propafenone appeared to be safe in the EAST-AFNET 4 trial to deliver effective ERC therapy, including in selected patients with stable cardiovascular disease such as coronary artery disease and stable heart failure. CLINICAL TRIAL REGISTRATION ISRCTN04708680, NCT01288352, EudraCT2010-021258-20, www.easttrial.org.
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Affiliation(s)
- Andreas Rillig
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
| | - Lars Eckardt
- Atrial Fibrillation Network (AFNET), Münster, Germany
- Department of Cardiology II - Electrophysiology, University Hospital Münster, Germany
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George's University of London, UK
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Netherlands
| | - Andreas Goette
- Atrial Fibrillation Network (AFNET), Münster, Germany
- St. Vincenz Hospital, Paderborn, Germany
- Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Germany
| | - Günter Breithardt
- Atrial Fibrillation Network (AFNET), Münster, Germany
- Department of Cardiology II - Electrophysiology, University Hospital Münster, Germany
| | - Marc D Lemoine
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
| | - Laura Rottner
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
| | | | - Eik Vettorazzi
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Karl Wegscheider
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
- Atrial Fibrillation Network (AFNET), Münster, Germany
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Hein Heidbuchel
- Department of Cardiology, Faculty of Medicine and Health Sciences, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
- Cardiovascular Research, GENCOR, Faculty of Medicine and Health Sciences, Antwerp University, Antwerp, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Stephan Willems
- Asklepios Klinik St. Georg, Klinik für Kardiologie und internistische Intensivmedizin, Hamburg, Germany
| | - Larissa Fabritz
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
- Atrial Fibrillation Network (AFNET), Münster, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
- Atrial Fibrillation Network (AFNET), Münster, Germany
| | - Christina Magnussen
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany
- Atrial Fibrillation Network (AFNET), Münster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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Deering TF, Piccini JP, Graf M, Chou JW, Wilson R, Land N, McKindley DS, Singh CM, Blomström-Lundqvist C. Expert Consensus on Comprehensive Early Rhythm Control in Addition to Guideline-Based Care for Atrial Fibrillation: A Modified Delphi Survey. Am J Cardiol 2023; 207:328-335. [PMID: 37774474 DOI: 10.1016/j.amjcard.2023.08.004] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 10/01/2023]
Abstract
Atrial fibrillation (AF) practice guidelines recommend a rhythm-control strategy to improve symptoms and quality of life, noting the side effects of antiarrhythmic drugs and catheter ablation. Emerging evidence indicates that comprehensive early rhythm control with antiarrhythmic drugs or catheter ablation is associated with a lower risk of adverse cardiovascular outcomes versus the usual care. Using an online modified Delphi survey approach, perspectives and expert consensus among electrophysiologists were examined through a series of ranking and likelihood questions around treatment decision-making on (1) the use of comprehensive early rhythm-control strategies in patients with AF based on guidelines and emerging research and (2) treatment selection factors. A panel of 17 electrophysiologists reached a consensus on using early rhythm control (median 90, interquartile range 14) based on the view that early intervention improved cardiovascular outcomes (mean rank 1.6 of 3, 82% within 1 SD) and symptoms (1.8 of 3, 41%). AF-related symptoms were identified as the most important in making a treatment initiation decision (1.1 of 7, 88%), followed by AF type (2.5 of 7, 82%). Participants were most likely to initiate treatment at AF symptom onset (median 80; interquartile range 6). In making treatment selection decisions, participants ranked short-term/long-term safety (1.9 of 7, 88%) and efficacy (1.8 of 7, 53%) as the top 2 considerations. In conclusion, experts were in favor of early rhythm control; however, additional research is needed to address the role that early rhythm-control strategies play in current AF treatment management algorithms.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Carina Blomström-Lundqvist
- Department of Medical Science, Uppsala University, Uppsala, Sweden; Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Han S, Jia R, Cen Z, Guo R, Zhao S, Bai Y, Xie M, Cui K. Early rhythm control vs. rate control in atrial fibrillation: A systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:978637. [PMID: 36815025 PMCID: PMC9939510 DOI: 10.3389/fcvm.2023.978637] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 06/26/2022] [Accepted: 01/19/2023] [Indexed: 02/08/2023] Open
Abstract
Objective It has long been debated whether rhythm control vs. rate control strategies have differing effects on mortality and morbidity for atrial fibrillation (AF). Recently, several randomized controlled studies (RCTs) and observational trials described that an early rhythm management method was linked to a lower likelihood of negative clinical outcomes in individuals with AF. We wanted to see if an early rhythm management method may help patients with AF. Methods We performed a systematic search to retrieve studies assessing the outcomes of early rhythm control vs. rate control in AF by using PubMed, Web of Science, Cochrane Library, and Embase published between 01/01/2000 and 15/04/2022. Results Finally, two RCTs, one retrospective analysis of RCTs, and four observational studies were identified. Compared with rate control, early rhythm control has been linked to lower all-cause mortality. [risk ratio (RR), 0.76; 95% CI 0.69-0.83; P < 0.00001; I 2 = 77%]. The early rhythm control group was also associated with a lower risk of cardiovascular mortality (RR, 0.68; 95% CI 0.63-0.74; P < 0.00001; I 2 = 33), stroke (RR, 0.77; 95% CI 0.67-0.87; P < 0.001; I 2 = 64), and heart failure hospitalization (RR, 0.74; 95% CI 0.59-0.93; P = 0.0009; I 2 = 93%). We found no significant difference in nights spent in hospital per year, acute coronary syndrome, major bleeding, and cardiac arrest/ventricular arrhythmia between the groups. Conclusion In this meta-analysis, early rhythm therapy was linked to a lower risk of all-cause mortality, cardiovascular mortality, stroke, and heart failure hospitalization compared with the rate control group. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022333592.
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Affiliation(s)
- Shaojie Han
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ruikun Jia
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhifu Cen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ran Guo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Shenyu Zhao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yixuan Bai
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Min Xie
- Department of Cardiology, Chengdu Seventh People’s Hospital, Chengdu, Sichuan, China,Min Xie,
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Kaijun Cui,
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