A 62-year-old man with persistent AF and a CHA₂DS₂-VASc score of 3 (prior stroke, hypertension) has had good rate control but remains in AF at 6 months. He is on rivaroxaban. The EAST-AFNET 4 trial (2020) showed that early rhythm control in recently diagnosed AF (within 1 year):
- A Did not improve outcomes compared to rate control
- B Significantly reduced a composite of CV death, stroke, and hospitalisation for heart failure or ACS ✓
- C Reduced stroke but increased risk of major bleeding
- D Showed benefit only in patients with HFrEF
Explanation
EAST-AFNET 4 (NEJM 2020) randomised 2789 patients with recently diagnosed AF (within 1 year) to early rhythm control versus usual rate control. Early rhythm control significantly reduced the primary composite outcome (CV death, stroke, hospitalisation for HF or ACS) by 21% at 5.1 years (HR 0.79; p=0.005), without excess serious adverse events. This was the first large trial to show a hard endpoint benefit of rhythm control, in contrast to older trials (AFFIRM/RACE) which showed no difference. Benefit was seen regardless of symptoms or HF status, supporting consideration of early cardioversion/AAD in newly diagnosed AF.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.