Based on subanalyses of participants with multiple cardiovascular comorbidities in the EAST-AFNET 4 trial, researchers suggested a CHA2DS2-VASc score of 4 was an effective indication for early rhythm control (ERC) to reduce adverse cardiovascular outcomes in recently diagnosed patients with atrial fibrillation and risk factors for stroke; however, patients with a lower comorbidity burden may achieve less favorable outcomes.
This study, published in Circulation, reviewed outcomes of ERC and usual care (UC) in 2789 patients categorized as either higher (CHA2DS2-VASc score ≥ 4) or lower (CHA2DS2-VASc score < 4) comorbidity burden.
ERC for Atrial Fibrillation Lacks Efficacy in Patients With Lower Comorbidity Burden
Compared with UC, ERC effectively reduces the primary composite outcome of cardiovascular death, hospitalization for worsening heart failure, stroke, and acute coronary syndrome for patients with events in the higher comorbidity burden group (ERC, 127/549 patients; UC, 183/544 patients; hazard ratio [HR], 0.64; 95% CI, 0.51-0.81; P<.001) but not for those with events in the lower comorbidity burden group (ERC, 122/846 patients; UC, 133/850 patients; HR, 0.93; 95% CI, 0.73-1.19; P=.56; interaction, P=.037).
Likewise, primary safety outcomes were comparable between UC and ERC in patients with higher comorbidity burden (HR, 0.84; 95% CI, 0.65-1.08; P=.175) but were more frequent among patients with lower comorbidity who received ERC (HR, 1.39; 95% CI, 1.05-1.82; P=.019; interaction, P=.008). The authors did note that rates of life-threatening events or death were similar between the groups.
In their full report, the authors summarized that “patients with recently diagnosed AF and multiple cardiovascular comorbidities should have rapid, priority access to rhythm control therapy to reduce cardiovascular outcomes.”
They further suggested that “the safety signal identified in these analyses highlights the need to develop safer ways to deliver ERC, especially in patients with few cardiovascular conditions.”