The Year in Cardiovascularmedicine 2020: Arrhythmias

Harry J.G.M. Crijns; Frits Prinzen; Pier D. Lambiase; Prashanthan Sanders; Josep Brugada


Eur Heart J. 2021;42(5):499-507. 

In This Article

Randomized Trials on Rhythm Control in Atrial Fibrillation

The EAST-AFNET 4 trial compared a rhythm with a rate control strategy in patients with early AF lasting <1 year. It showed that rhythm control therapy, i.e. antiarrhythmic drugs and ablation, in early AF reduced cardiovascular outcomes without increasing time spent in-hospital, and without safety concerns.[15] The results are at odds with older trials, which may relate to earlier intervention, safer use of antiarrhythmic drugs, and safe application of catheter ablation. In accordance with the AF Guidelines,[1,16–18] rhythm control was applied on top of cardiovascular prevention. Like previous trials,[19–21] EAST-AFNET4 was a strategy evaluation and not a simple comparison of two treatment modalities meant to either maintain sinus rhythm or keeping adequate rate control like the CABANA trial.[22] EAST-AFNET4 included recently detected AF, which seems crucial since most events occur in the first year after AF detection.[23,24] Early intervention is supported by two recent trials showing that cryoballoon ablation as initial therapy is superior to drug treatment.[25,26] Therefore, initial AF care should be supervised by cardiologists rather than non-cardiologists since 1-year mortality and morbidity are lower if newly diagnosed AF is managed under cardiology care compared to non-cardiology care.[27,28]

Early rhythm control in recent-onset AF in the emergency room was tested in another randomized study comparing procainamide and rescue electrical cardioversion if needed with immediate electrical cardioversion.[29] Both strategies were clinically highly effective, but the authors suggested that immediate cardioversion be preferred since less burdensome for patients and the hospital.

Catheter ablation may be particularly useful in heart failure with AF,[21,30] to improve quality of life[31,32] as well as to save costs.[33] One interesting observational study suggested that catheter ablation compared to drug treatment is associated with a lower incidence of vascular dementia.[34] To support or circumvent catheter ablation, recent reports advocated add-on renal denervation[35] or low level tragus stimulation.[36] In CASA-AF,[37,38] single procedure thoracoscopic surgical left atrial posterior wall isolation was not superior to extensive point-by-point posterior wall isolation plus right and left isthmus ablation and came with higher costs and less gain in QALYs. However, the surgical lesion set was quite limited and surgical learning curve effects may have affected outcome.