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Effectiveness and Safety of Early Rhythm Control in Patients With Atrial Fibrillation and Chronic Kidney Disease
Niklas Schenker1, Katrin Borof1, Andreas Goette2
1University Heart and Vascular Center Hamburg, Department of Cardiology, Hamburg, Germany.
Insights
Early rhythm control (ERC) effectively reduces cardiovascular events in patients with atrial fibrillation (AF) and chronic kidney disease (CKD). This strategy is safe and beneficial for both CKD and non-CKD patients.
Area of Science:
- Cardiology
- Nephrology
- Clinical Trials
Background:
- Atrial fibrillation (AF) poses significant cardiovascular risks, particularly in patients with chronic kidney disease (CKD).
- The established benefits and safety of early rhythm control (ERC) in CKD patients remain under investigation.
Purpose of the Study:
- To assess the effectiveness and safety of ERC in patients with CKD, defined by estimated glomerular filtration rate (GFR).
- This analysis is a predefined secondary objective of the EAST-AFNET 4 trial.
Main Methods:
- The EAST-AFNET 4 trial randomized patients with recent-onset AF and comorbidities to either ERC or usual care (UC).
- Outcomes were analyzed across CKD strata based on Kidney Disease Improving Global Outcomes criteria.
- Primary efficacy endpoint: composite of cardiovascular death, stroke, heart failure hospitalization, or acute coronary syndrome. Safety endpoint: composite of death, stroke, and serious rhythm control-related adverse events.
Main Results:
- 23% of patients had CKD (GFR <60 mL/min/1.73 m²). CKD patients were older with higher CHA₂DS₂-VASc scores.
- ERC significantly reduced the primary composite outcome in both non-CKD (HR 0.84) and CKD (HR 0.67) groups.
- CKD was associated with increased safety events and AF recurrences, but ERC's benefits persisted without significant interaction for primary efficacy or safety outcomes.
Conclusions:
- Early rhythm control (ERC) is an effective and safe strategy for reducing cardiovascular events in patients with recent-onset atrial fibrillation (AF) and stroke risk factors.
- These benefits extend to patients with and without chronic kidney disease (CKD).
- ERC also demonstrated a significant reduction in AF recurrences in CKD patients compared to usual care.
Background:
Atrial fibrillation (AF) increases cardiovascular risk in patients with chronic kidney disease (CKD). The safety and efficacy of early rhythm control (ERC) in patients with CKD is not fully established.
Objectives:
This predefined secondary analysis of the EAST-AFNET 4 trial assessed the effectiveness and safety of ERC in patients with CKD defined by estimated glomerular filtration rate (GFR).
Methods:
EAST-AFNET 4 randomized patients with recently diagnosed AF and comorbidities to ERC or usual care (UC). Key outcomes were analyzed by Kidney Disease Improving Global Outcomes defined CKD groups. The primary efficacy outcome combined cardiovascular death, stroke, hospitalization for worsening heart failure, or acute coronary syndrome. The safety outcome combined death, stroke, and serious rhythm control-related adverse events. Recurrent AF was a secondary outcome.
Results:
Baseline creatinine was available in 2,742 of 2,789 (98.3%) patients. In this study, 23% had CKD (GFR: <60 mL/min/1.73 m2). Patients with CKD were older (CKD: 74 ± 7.4 years; no CKD: 69 ± 8.3 years; P < 0.001), had higher CHA2DS2-VASc scores (CKD: 4 ± 1.4; no CKD: 3.2 ± 1.2; P < 0.001), and more primary outcome events over 5.1 years of follow-up (HR: 0.98 per mL GFR decrease [95% CI: 0.97-0.99 per mL GFR decrease]). ERC reduced the primary outcome with and without CKD (no CKD: ERC: 3.4%/100 patient-years; UC: 4.1%/100 patient-years; HR: 0.84; P < 0.001; CKD: ERC: 5.8%/100 patient-years; UC: 8.5%/100 patient-years; HR: 0.67; P < 0.001; Pinteraction = 0.133). CKD increased safety outcomes without interaction with ERC (Pinteraction = 0.927). Patients with CKD experienced more AF recurrences with UC (Pinteraction = 0.036).
Conclusion:
ERC effectively and safely reduces cardiovascular events in patients with recently diagnosed AF and stroke risk factors with and without CKD. (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST); NCT01288352).
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