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).
| Discipline Area | Score |
|---|---|
| Family Medicine (FM)/General Practice (GP) |  |
| General Internal Medicine-Primary Care(US) | |
| Cardiology | |
| Nephrology | |
| Internal Medicine |  |
AF ablation improves outcomes in CKD.
Practice-guiding insights. For AF diagnosed within the past year in CKD stages 3–4, early rhythm control (drug and/or ablation) should be routine because it safely reduces major CV events without harming renal function and is more effective than “usual” care in preventing recurrent AF.
This trial demonstrates the benefits of early rhythm control even in patients with CKD. Although no significant interactions were observed within the trial, it was shown that the risk increases with more severe CKD, suggesting that early rhythm control may be particularly important in patients with CKD.