AF patients with high comorbidity may benefit from early rhythm control

Early rhythm control (ERC) appears to cut the risk of adverse cardiovascular outcomes in atrial fibrillation (AF) patients with a CHA2DS2-VASc score of ≥4, a study has found.

Researchers used data from the EAST-AFNET4 trial to compare the effectiveness and safety of ERC with usual care stratified into patients with higher (CHA2DS2-VASc score ≥4) and lower comorbidity burden. EAST-AFNET4 included 1,093 patients with CHA2DS2-VASc score ≥4 (mean age 74.8 years, 61 percent female) and 1,696 with CHA2DS2-VASc score <4 (mean age 67.4 years, 37 percent female).

Compared with usual care, ERC was associated with a significantly lower frequency of the composite primary efficacy outcome of cardiovascular death, stroke, or hospitalization for worsening of heart failure or for acute coronary syndrome was lower in the group of patients with CHA2DS2-VASc score ≥4 (127/549 vs 183/544 patients with events; hazard ratio [HR], 0.64, 95 percent confidence interval [CI], 0.51–0.81; p<0.001).

Of note, the beneficial of ERC on the primary composite outcome did not extend to the group of patients with CHA2DS2-VASc score <4 (122/846 vs 133/850 patients with events; HR, 0.93, 95 percent CI, 0.73–1.19; p=0.56; p_interaction=0.037).

In terms of safety, there was no significant between-group difference seen in the composite of death, stroke, or serious adverse events related to rhythm control therapy in the CHA2DS2-VASc score ≥4 group (HR, 0.84, 95 percent CI, 0.65–1.08; p=0.175).

Conversely, the safety outcome occurred more often among ERC-treated patients in the CHA2DS2-VASc score <4 group (HR, 1.39, 95 percent CI, 1.05–1.82; p=0.019; p_interaction=0.008). Life-threatening events or deaths were similar in the treatment group, regardless of comorbidity burden.

In sensitivity analyses that discounted female sex for the creation of higher and lower risk groups (CHA2DS2-VA score), the interaction between ERC and comorbidity burden was not significant for the primary efficacy outcome (p=0.25) but remained significant (p=0.044) for the primary safety outcome.