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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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Zhu H, Xu X, Wang H, Chen Q, Fang X, Zheng J, Gao B, Tong G, Zhou L, Chen T, Huang J. Secondary prevention of antithrombotic therapy in patients with stable cardiovascular disease at high ischemic risk: A network meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 9:1040473. [PMID: 36698936 PMCID: PMC9869170 DOI: 10.3389/fcvm.2022.1040473] [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: 09/09/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Aims Antithrombotic secondary prevention in stable cardiovascular disease (SCVD) patients at high ischemic risk remains unclear. We compared the efficacy and safety of aspirin monotherapy, clopidogrel monotherapy, ticagrelor monotherapy, rivaroxaban monotherapy, clopidogrel plus aspirin, ticagrelor plus aspirin, and rivaroxaban plus aspirin in the high-risk ischemic cohorts. Methods and results Eleven randomized controlled trials were included (n = 111737). The primary outcomes were major cardiovascular and cerebrovascular events (MACEs) and major bleeding. A random effects model was used for frequentist network meta-analysis. Odds ratio (OR) and 95% credible intervals (CI) were reported as a summary statistic. Compared with aspirin monotherapy, rivaroxaban plus aspirin [OR 0.79 (95% CI, 0.69, 0.89)], ticagrelor plus aspirin [0.88 (0.80, 0.98)], clopidogrel plus aspirin [0.56 (0.41, 0.77)] were associated with a reduced risk of MACEs, but rivaroxaban monotherapy [0.92 (0.79, 1.07)], ticagrelor monotherapy [0.68 (0.45, 1.05)], and clopidogrel monotherapy [0.67 (0.43, 1.05)] showed no statistically significant difference. However, rivaroxaban monotherapy and all dual antithrombotic strategies increased the risk of major bleeding to varying degrees, with ticagrelor plus aspirin associated with the highest risk of major bleeding. The net clinical benefit favored clopidogrel or ticagrelor monotherapy, which have a mild anti-ischemic effect without an increase in bleeding risk. Conclusion The present network meta-analysis suggests that clopidogrel or ticagrelor monotherapy may be recommended first in this cohort of SCVD at high ischemic risk. But clopidogrel plus aspirin or rivaroxaban plus aspirin can still be considered for use in patients with recurrent MACEs.
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Affiliation(s)
- Houyong Zhu
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China,*Correspondence: Houyong Zhu,
| | - Xiaoqun Xu
- Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Hanxin Wang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qilan Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xiaojiang Fang
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jianwu Zheng
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Beibei Gao
- Department of Cardiology, The Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Guoxin Tong
- Department of Cardiology, The Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Liang Zhou
- Department of Cardiology, The Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Tielong Chen
- Department of Cardiology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China,Tielong Chen,
| | - Jinyu Huang
- Department of Cardiology, The Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China,Jinyu Huang,
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