Global Gains in Heart Function From Early AF Rhythm Control

March 15, 2022

The case for early rhythm control, achieved by ablation or cardioversion, in most patients with atrial fibrillation (AF) is mechanistically stronger with a new study suggesting the strategy can improve structural and functional heart damage from the arrhythmia.

Patients with recently diagnosed AF who achieved sinus rhythm (SR) after cardioversion or catheter ablation showed anatomic and functional signs of global reverse remodeling and lessened severity of tricuspid- and mitral-valvular regurgitation.

The benefits observed on echocardiography accrued primarily to the study's patients in whom SR was actively restored with a procedure or drugs, and less so to those who spontaneously reverted to SR during the first day of hospital admission, researchers report.

The findings, based on a year follow-up of 117 adults hospitalized with paroxysmal or persistent AF, were published in the March 15 issue of the Journal of the American College of Cardiology, with lead author Laurie Soulat-Dufour, MD, PhD, Sorbonne Université, Paris.

Early rhythm control has expanded as a go-to strategy for AF since the 2020 publication of EAST-AFNET 4, in which it appeared to significantly and safely cut the risk for death, stroke, and heart-failure events over 5 years, compared with a usual-care approach that started with pharmacologic rate-control therapy.

The current study, with its demonstration of significant right- and left-atrial (RA and LA) reverse remodeling and improved cardiac function after active restoration of SR, as the report observes, provides mechanistic support for the pursuit of an early rhythm-control strategy in more patients with a recent AF diagnosis.

"In clinical practice, restoration of SR should be vigorously attempted" to improve reverse remodeling "and severity of functional regurgitation in AF," the authors state.

"Time Course and Impact" of Achieving SR

The current findings "go some way in explaining the time course and impact of returning AF to SR," which, potentially, could "significantly influence decision-making in AF," says an accompanying editorial from Thomas H. Marwick, MBBS, PhD, MPH, Baker Heart and Diabetes Institute, Melbourne, Australia, and Nicolas Brugger, MD, University of Bern, Switzerland.

They "provide an important cardiac anatomical and functional perspective on the merits of intervention for AF" and "offer some encouragement to the notion that AF rhythm control may be beneficial to myocardial function," the pair writes.

"We hope that it provokes clinical trials to help document the beneficial effects of rhythm control strategies on myocardial function" and functional mitral and tricuspid regurgitation.

The analysis, based on data from the prospective FASTRHAC study of patients in France who were hospitalized for AF, followed 117 patients without known valvular disease by serial 3-dimensional echocardiography (3DE) for 12 months.

Sinus rhythm was actively restored by cardioversion or ablation in 86 patients, of whom 47 remained in SR and 39 were found to have AF at 12 months.

The remaining 31 patients reverted to SR spontaneously within 24 hours, after which further management could include ablation or drug therapy.

3D Echo Findings

The 40.2% of patients who achieved and maintained SR for 12 months after cardioversion or ablation, the report notes, showed:

  • Decreased LA and RA indexed volumes, and end-systolic RV indexed volumes

  • Increased end-diastolic LV indexed volumes

  • Improved tricuspid and mitral valvular regurgitation

The 26.5% of patients who reverted to SR spontaneously in the hospital and who were in SR at 12 months showed no changes in indexed chamber volumes or functional measures but improvement in tricuspid regurgitation.

The 33.3% of patients with AF at 12 months showed:

  • Increased end-diastolic and end-systolic RV indexed volumes and end-diastolic LA index volumes

  • No changes in cardiac function in 4-chamber view, except for decreased LA emptying fraction

Intervention with cardioversion, ablation, or both was the only significant predictor of RA and LA reverse remodeling at 12 months in multivariate analysis, with an odds ratio of 26.93 (95% CI, 3.0 - 241; P = .003).

The authors acknowledge that their study is small and has other limitations, including technical aspects of 3DE as performed that were not "guidelines-compatible" and which should be confirmed by "other modes of 3D acquisition or other modalities of imaging to ensure the reproducibility of the measurements."

Also, they write, "one year is probably too short to document cardiac remodeling; 2-year follow-up is currently ongoing."

The study was "partially funded by Bayer and the Fondation de France." Soulat-Dufour discloses receiving a grant from Fédération Française de Cardiologie; disclosures for the other authors are in the report. Marwick and Brugger have "no relevant relationships" to disclose.

J Am Coll Cardiol. 2022;79:951-961, 962-964. Abstract, Editorial

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