Effectiveness of early rhythm control in improving clinical outcomes in patients with atrial fibrillation: a systematic review and meta-analysis

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: atrial fibrillation (n=447202). Intervention: Early rhythm control vs. Rate control. Primary outcome: Composite of death, stroke, admission to hospital for heart failure (HF), or acute coronary syndrome (ACS) (HR 0.88, 95% CI 0.86-0.89).

Wengen Zhu; Zexuan Wu; Yugang Dong; Gregory Y.H. Lip; Chen Liu

doi:10.1186/s12916-022-02545-4

October 13, 2022BMC MedicineOpen Access

Effectiveness of early rhythm control in improving clinical outcomes in patients with atrial fibrillation: a systematic review and meta-analysis

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Key result

Early rhythm control significantly reduced the composite outcome of death, stroke, heart failure hospitalization, or acute coronary syndrome (HR 0.88) compared to rate control in newly diagnosed AF.

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Why the study?

Long-term prognostic outcomes of rhythm control compared with rate control in patients with atrial fibrillation remain inconclusive.

Does early rhythm control reduce the composite of death, stroke, HF hospitalization, or ACS compared to rate control in patients with newly diagnosed atrial fibrillation?

Study Design

Type

Meta-Analysis (n=447,202)

Structured PICO

Does early rhythm control reduce the composite of death, stroke, HF hospitalization, or ACS compared to rate control in patients with newly diagnosed atrial fibrillation?

P

Population

447,202 patients with newly diagnosed atrial fibrillation (within 12 months of diagnosis) followed for 1.85 to 5.1 years.

I

Intervention

Early rhythm control therapy (initiated within 12 months of AF diagnosis), including a mixed treatment strategy of ablation, cardioversion, or antiarrhythmic drugs (AADs).

C

Comparator

Rate control therapy.

O

Outcome

Composite of death, ischemic or hemorrhagic stroke, hospitalization with heart failure (HF), or acute coronary syndrome (ACS).composite

Main Result

Hazard Ratio: 0.88 (95% CI 0.86–0.89)

Early initiation of rhythm control within 1 year of atrial fibrillation diagnosis is associated with a significantly lower risk of adverse cardiovascular outcomes compared to rate control.

Limitations

Significant varieties in study designs and endpoints, with mostly observational and post hoc analyses and only one primary RCT.
Potential unmeasured risk factors affecting validity.
Modest number of included studies limited the application of meta-regression.
Did not consider safety outcomes or quality of life.
Mixed treatment strategy of ablation, cardioversion, or AADs in the early rhythm-control group.
Included mostly observational and post hoc analyses, with only one primary RCT
Several unmeasured risk factors might exist and affect the validity of findings
Modest number of included studies limited the application of meta-regression
Did not consider safety outcomes or quality of life
Heavily weighted towards one large retrospective observational study (Chao et al.)
Included a mixed treatment strategy of ablation, cardioversion, or AADs in the early rhythm-control group

Implication

Supports early rhythm control in new AF to lower major events; extends large observational data but leaves definitive RCTs open.

Abstract

BACKGROUND: Current guidelines recommend rhythm control for improving symptoms and quality of life in symptomatic patients with atrial fibrillation (AF). However, the long-term prognostic outcomes of rhythm control compared with rate control are still inconclusive. In this meta-analysis, we aimed to assess the effects of early rhythm control compared with rate control on clinical outcomes in newly diagnosed AF patients. METHODS: We systematically searched the PubMed and Embase databases up to August 2022 for randomized and observational studies reporting the associations of early rhythm control (defined as within 12 months of AF diagnosis) with effectiveness outcomes. The primary outcome was a composite of death, stroke, admission to hospital for heart failure (HF), or acute coronary syndrome (ACS). Hazard ratios (HRs) and 95% confidence intervals (CIs) from each study were pooled using a random-effects model, complemented with an inverse variance heterogeneity or quality effects model. RESULTS: A total of 8 studies involving 447,202 AF patients were included, and 23.5% of participants underwent an early rhythm-control therapy. In the pooled analysis using the random-effects model, compared with rate control, the early rhythm-control strategy was significantly associated with reductions in the primary composite outcome (HR = 0.88, 95% CI: 0.86-0.89) and secondary outcomes, including stroke or systemic embolism (HR = 0.78, 95% CI: 0.71-0.85), ischemic stroke (HR = 0.81, 95% CI: 0.69-0.94), cardiovascular death (HR = 0.83, 95% CI: 0.70-0.99), HF hospitalization (HR = 0.90, 95% CI: 0.88-0.92), and ACS (HR = 0.86, 95% CI: 0.76-0.98). Reanalyses using the inverse variance heterogeneity or quality effects model yielded similar results. CONCLUSIONS: Our current meta-analysis suggested that early initiation of rhythm control treatment was associated with improved adverse effectiveness outcomes in patients who had been diagnosed with AF within 1 year. REGISTRATION: The study protocol was registered to PROSPERO (CRD42021295405).

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Cite This Study

Zhu et al. (2022) conducted a meta-analysis in atrial fibrillation (n=447,202). Early rhythm control vs. Rate control was evaluated on Composite of death, stroke, admission to hospital for heart failure (HF), or acute coronary syndrome (ACS) (HR 0.88, 95% CI 0.86-0.89). Early rhythm control significantly reduced the composite outcome of death, stroke, heart failure hospitalization, or acute coronary syndrome (HR 0.88) compared to rate control in newly diagnosed AF.

synapsesocial.com/papers/6a33031858530ca2eee121c9 https://doi.org/10.1186/s12916-022-02545-4