Early Rhythm Control (ERC) in Atrial Fibrillation – Evidence & Guideline Summary
Early Rhythm Control (ERC) in Atrial Fibrillation – Evidence & Guideline Summary
Source : JAMA Cardiol
Published Online: July 30, 2025
1. Scientific Evidence
• EAST-AFNET 4 Trial (NEJM 2020):
• Enrolled patients with newly diagnosed AF (≤12 months).
• Compared Early Rhythm Control (ERC) (antiarrhythmic drugs, ablation, or cardioversion) vs Usual Care (mainly rate control).
• Showed significant reduction in:
• Stroke
• Cardiovascular death
• Hospitalization due to heart failure or acute coronary syndrome.
• Sub-analyses (JAMA Cardiol 2025, etc.):
• Benefit of ERC is consistent in high-risk groups, including:
• Patients with obesity
• Patients with diabetes
• Older adults (mean age ~70 in trial).
• Neither obesity nor diabetes should be a reason to withhold ERC.
2. ESC 2020 AF Guidelines – Position on ERC
• ERC in newly diagnosed AF (≤12 months):
• Class IIa, Level of Evidence B
• Meaning: “should be considered” but not yet a Class I recommendation because evidence comes mainly from one large RCT (EAST-AFNET 4), not multiple confirmatory RCTs.
3. Class I Indications for Rhythm Control (Strong Recommendations)
According to ESC 2020 AF Guidelines:
• Symptomatic AF
• Rhythm control is Class I if symptoms persist despite adequate rate control.
• Heart Failure with Reduced Ejection Fraction (HFrEF, LVEF ≤40%)
• Rhythm control (especially catheter ablation) is Class I because it improves symptoms and cardiac function.
• Tachycardia-induced Cardiomyopathy
• Rhythm control is Class I to reverse LV dysfunction and restore normal cardiac performance.
• Post-ablation recurrence (if symptomatic):
• Re-attempt at rhythm control is Class I in selected patients.
4. Practical Clinical Takeaways
• Newly Diagnosed AF:
• ERC should be considered early (Class IIa) for all, not just symptomatic patients, based on EAST-AFNET 4.
• Do NOT delay ERC in high-risk groups:
• Obese patients, diabetics, elderly patients – all benefit equally from early intervention.
• Clear-cut Class I cases (strongest recommendation):
• Symptomatic AF refractory to rate control.
• AF with HFrEF (LVEF ≤40%).
• Tachycardia-induced cardiomyopathy.
• Symptomatic AF recurrence after ablation.
In summary:
• ERC is safe and effective in newly diagnosed AF patients, with or without obesity/diabetes (Class IIa, Level .
• Strong Class I recommendation for rhythm control applies only to symptomatic AF, AF with HFrEF, tachycardia-induced cardiomyopathy, and symptomatic recurrence post-ablation.
