Early Rhythm Control Therapy for Atrial Fibrillation in Low-Risk Patients A Nationwide Propensity Score-Weighted Study

Daehoon Kim, Pil Sung Yang, Seng Chan You, Eunsun Jang, Hee Tae Yu, Tae Hoon Kim, Hui Nam Pak, Moon Hyoung Lee, Gregory Y.H. Lip, Jung Hoon Sung, Boyoung Joung

Research output: Contribution to journalArticlepeer-review

1 Citation (Scopus)


Background: Rhythm control is associated with lower risk for adverse cardiovascular outcomes compared with usual care among patients recently diagnosed with atrial fibrillation (AF) with a CHA2DS2-VASc score of approximately 2 or greater in EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial). Objective: To investigate whether the results can be generalized to patients with low stroke risk. Design: Population-based cohort study. Setting: Nationwide claims database of the Korean National Health Insurance Service. Participants: 54 216 patients with AF having early rhythm control (antiarrhythmic drugs or ablation) or rate control therapy that was initiated within 1 year of the AF diagnosis. Measurements: The effect of early rhythm control on the primary composite outcome of cardiovascular death, ischemic stroke, hospitalization for heart failure, or myocardial infarction was compared between eligible and ineligible patients for EAST-AFNET 4 (CHA2DS2-VASc score, approximately 0 to 1) using propensity overlap weighting. Results: In total, 37 557 study participants (69.3%) were eligible for the trial (median age, 70 years; median CHA2DS2-VASc score, 4), among whom early rhythm control was associated with lower risk for the primary composite outcome than rate control (hazard ratio, 0.86 [95% CI, 0.81 to 0.92]). Among the 16 659 low-risk patients (30.7%) who did not meet the inclusion criteria (median age, 54 years; median CHA2DS2-VASc score, 1), early rhythm control was consistently associated with lower risk for the primary outcome (hazard ratio, 0.81 [CI, 0.66 to 0.98]). No significant differences in safety outcomes were found between the rhythm and rate control strategies regardless of trial eligibility. Limitation: Residual confounding. Conclusion: In routine clinical practice, the beneficial association between early rhythm control and cardiovascular complications was consistent among low-risk patients regardless of trial eligibility.

Original languageEnglish
Pages (from-to)1356-1365
Number of pages10
JournalAnnals of Internal Medicine
Issue number10
Publication statusPublished - 2022 Oct

Bibliographical note

Funding Information:
This research was supported by the Ministry of Health and Welfare and the Ministry of Food and Drug Safety of the Republic of Korea, which had no role in study design; collection, analysis, or interpretation of data; writing of the report; or the decision to submit the manuscript for publication.

Funding Information:
Grant Support: By grant HC19C0130 from the Patient-Centered Clinical Research Coordinating Center funded by the Ministry of Health and Welfare, Republic of Korea, and by grant 22213MFDS486 from the Ministry of Food and Drug Safety, Republic of Korea.

Publisher Copyright:
© 2022 American College of Physicians. All rights reserved.

All Science Journal Classification (ASJC) codes

  • Internal Medicine


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