Dr. John Day, Cardiologist

4 Reasons Why Normal Sinus Rhythm Beats Atrial Fibrillation

The long awaited EAST-AF Study was finally published and the results were compelling–normal sinus rhythm beats atrial fibrillation. If you or a loved one is battling atrial fibrillation the results of this study could completely change the way you and your cardiologist treats atrial fibrillation. No longer should atrial fibrillation be ignored–as long as it can be caught early hitting it hard is your best chance at maintaining normal sinus rhythm and avoiding long-term complications from atrial fibrillation.

The EAST-AF Study

The EAST-AF Study was an international study of 2,789 patients from 135 hospitals in 11 different countries. And after an average follow up of 5.1 years per patient, the study was stopped early because the early results clearly showed that normal sinus rhythm beats atrial fibrillation.

Which Atrial Fibrillation Patients Were Included in this Study?

Understanding which patients were studied in EAST-AF is critical to applying it to your own situation. To even be considered for this study you had to have newly diagnosed atrial fibrillation.  This is an important feature as the longer you are out of rhythm the harder it is to ever get your heart back in normal sinus rhythm.  In fact, the median number of days from atrial fibrillation diagnosis to enrollment in this study was just 36 days.

Once you met the criteria of new onset atrial fibrillation, there were three different ways you could get into this study.  The first way was to have atrial fibrillation and be 75 years old.

The second way to get into this study was to have newly diagnosed atrial fibrillation with a history of a stroke or TIA (“mini-stroke”).

The third way to get into this study was to have new onset atrial fibrillation and be 65 years old with any two of the following risk factors: female sex, high blood pressure, diabetes, severe coronary artery disease (prior heart attack, heart stent, or heart bypass surgery), heart failure, a thickened heart, chronic kidney disease, or peripheral vascular disease.

The bottom line is that the atrial fibrillation patients evaluated in this study all had newly diagnosed atrial fibrillation and were either older or suffered from other medical conditions. And after being eligible for the study you were then randomized to “usual” atrial fibrillation care or aggressive atrial fibrillation care.

What Was “Usual” Atrial Fibrillation Care in this Study?

The usual care for atrial fibrillation was that you were prescribed a blood thinner and a second medicine to slow your heart down.  And as long as your symptoms weren’t too bothersome, they just let your heart stay in atrial fibrillation.

To many readers this might sound rather barbaric.  Just take drugs and don’t worry if your heart out of rhythm.  However, based on flawed studies from 20 years ago, most physicians still today make no effort to keep your heart in rhythm unless you report horrible symptoms from atrial fibrillation.  It still amazes me that poorly designed studies from 20 years ago doomed an entire generation of atrial fibrillation patients to a life without normal sinus rhythm.

What Was Aggressive Atrial Fibrillation Care in this Study?

In order to keep the people in normal sinus rhythm in the EAST-AF Study, aggressive treatment meant that physicians could try any combination of the following three options:

1. An anti-arrhythmic medication like Dronedarone, Amiodarone, Flecainide, or Propafenone.

2. Cardioversion where the heart is shocked back into normal sinus rhythm.

3. Catheter ablation.

How Did They Determine Whether or Not Normal Sinus Rhythm Beats Atrial Fibrillation?

Before the EAST-AF Study ever enrolled their first patient, it was decided ahead of time that the winner of this study would be the group of patients who had the fewest number of patients experiencing the combined end-point of cardiovascular death, stroke, TIA (mini-stroke), or hospitalization for worsening heart failure or coronary artery disease.

In all fairness, aggressively pursuing normal sinus rhythm wasn’t without complications.  As most patients took an anti-arrhythmic to maintain normal sinus rhythm there were a number of complications from these medications.  While only 20% of the aggressive treatment group underwent a catheter ablation procedure, the results were so good from this small group of ablation patients that the authors of the study felt that this is what tipped the balance of the study to show sinus rhythm beats atrial fibrillation.

4 Reasons Why Sinus Rhythm Beats Atrial Fibrillation

Now that we’ve covered the basics of the study, let’s get to what it showed.  And below are the 4 reasons why normal sinus rhythm beats atrial fibrillation according to the EAST-AF Study.

1. Doing whatever it takes to keep your heart in normal sinus rhythm decreased your combined risk of something really bad happening by 21%.  And really bad in this study was defined as a cardiac death, stroke/mini-stroke, or getting hospitalized for worsening heart failure or coronary artery disease.

2. Aggressive atrial fibrillation treatment resulted in many more hearts maintaining normal sinus rhythm.  In fact, 85% of patients with aggressive treatment were in normal sinus rhythm a year later with only a slight decrease over time.

3. Having a goal of maintaining normal sinus rhythm decreased the risk of stroke by 35%.

4. Keeping your heart in rhythm was associated with a 28% less risk of a cardiac death.

My Take on This Study

This study fits nicely with our experience in taking care of tens of thousands of patients with atrial fibrillation over the last 30 years. It also validates our previous studies showing that you have to hit atrial fibrillation early and hard if you want to maintain normal sinus rhythm long-term. Also, our research has shown that maintaining normal sinus rhythm may prevent an early death, strokes, and dementia which is right in line with the EAST-AF Study.

If you want to see my additional comments, I was interviewed in this news report on the EAST-AF Study:

https://www.healio.com/news/cardiology/20200829/eastafnet-4-early-rhythm-control-for-af-reduces-risk-for-poor-cv-outcomes

Did you like the photograph with this article? It shows my daughter perfectly in rhythm doing a handstand on the beach with two of my sons watching her from the water.