A 52-year-old man with paroxysmal atrial fibrillation (no structural heart disease) has had 3 symptomatic episodes over 6 months. His CHA₂DS₂-VASc score is 2 (hypertension, age). He requests rate vs. rhythm control. The EAST-AFNET 4 trial (2020) significantly changed the AF management paradigm by demonstrating:
- A Rate control was superior to rhythm control for reducing death and stroke in paroxysmal AF
- B No difference between early rhythm control and rate control — consistent with AFFIRM trial
- C Ablation was superior to antiarrhythmics in newly diagnosed AF for preventing MACE
- D Early rhythm control (within 1 year of diagnosis) significantly reduced death, stroke, and hospitalisation for HF or ACS compared to usual care (predominantly rate control) ✓
Explanation
EAST-AFNET 4 (NEJM 2020) randomly assigned 2789 patients with early AF (diagnosed ≤ 1 year) to early rhythm control vs. usual care and showed that early rhythm control significantly reduced the composite of cardiovascular death, stroke, or hospitalisation for HF or ACS at 5-year follow-up (3.9 vs. 5.0% per year; HR 0.79). This was in contrast to AFFIRM (2002) which enrolled longer-standing AF and found no mortality difference. ESC 2020 guidelines incorporated EAST-AFNET 4 findings, promoting early rhythm control as preferred when feasible, particularly in patients with low bleeding risk and significant symptoms.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.