Patients with atrial fibrillation and heart failure benefit from early rhythm control

Press release

A subgroup analysis of the EAST – AFNET 4 study population revealed: Early initiation of rhythm control therapy is associated with clinical benefit in patients with heart failure and recently diagnosed atrial fibrillation. The new findings were presented by Dr. Andreas Rillig, UKE Hamburg, at the HRS congress on 30.07.2021 [1], [2].  

Atrial fibrillation (AF) and heart failure (HF) are two cardiovascular epidemics which often appear together. Approximately 30 % of patients with atrial fibrillation suffer from heart failure. These patients with both conditions are at particular risk of cardiovascular complications including death, stroke, and worsening of heart failure. Recent studies suggest that rhythm control therapy using atrial fibrillation ablation could improve left ventricular function in patients with atrial fibrillation and heart failure, and that this may lead to improved outcomes. However, further evidence illustrating these effects in different HF subtypes is needed.

The EAST – AFNET 4 trial investigated whether rhythm control therapy – with antiarrhythmic drugs or ablation – delivered within one year after AF diagnosis improves outcomes. The main study result, published last year [3], demonstrated a clinical benefit of early rhythm control therapy for all patients: Early rhythm control therapy with antiarrhythmic drugs and/or AF ablation reduced a composite of cardiovascular death, stroke, and hospitalization for worsening heart failure or acute coronary syndrome in 2789 patients with early AF and cardiovascular risk factors compared to usual care over a 5-year follow-up time.  

Now the EAST – AFNET 4 investigators studied whether the beneficial effects of early rhythm control can be transferred to the subgroup of HF patients. Principal investigator Professor Paulus Kirchhof of the University Heart and Vascular Centre UKE Hamburg, Germany, explains: “Rhythm control is an important component of AF management in HF patients. However, it is not clear, whether rhythm control therapy conveys clinical benefit in patients with moderately reduced or preserved left ventricular ejection fraction (LVEF). To answer this question, we analyzed the effect of early rhythm control in patients with HF enrolled into the EAST – AFNET 4 trial.”

The analysis includes 798 patients with HF (785 with known LVEF at baseline). The majority, 442 patients, had HF with preserved LVEF (LVEF≥50%), 211 HF with mid-range LVEF (LVEF40-49%), and 132 HF with reduced LVEF (LVEF<40%). 396 patients were randomized to early rhythm control, 402 to usual care.

Over the 5.1-year median follow-up, the composite primary outcome of cardiovascular death, stroke or hospitalization for worsening of HF or for acute coronary syndrome occurred less frequently in HF patients randomized to early rhythm control (94/396; 5.7 per 100 patient-years) compared to HF patients randomized to usual care (130/402; 7.9 per 100 patient-years).

Early rhythm control therapy was safe in patients with HF. The primary safety outcome – defined as a composite of death, stroke, or serious adverse events of rhythm control therapy – occurred in 71/396 (17.9%) HF patients on early rhythm control and in 87/402 (21.6%) on usual care. Left ventricular function improved in both groups.

Dr. Rillig concludes: “The results of this analysis demonstrate a clinical benefit of early rhythm control therapy for all HF patients of the EAST – AFNET 4 trial. Early rhythm control based on either antiarrhythmic drug therapy or catheter ablation should be offered to all patients with AF and symptoms of HF or reduced LVEF.”


[1] Rillig A, Ozga A, Magnussen C, Brandes A, Breithardt G, Camm AJ, Crijns HJGM, Eckardt L, Elvan A, Gulizia M, Haegeli LM, Heidbuchel H, Kuck KH, Ng GA, Szumowski L, van Gelder IC, Wegscheider K, Kirchhof P. Early rhythm control therapy in patients with atrial fibrillation and heart failure. Abstract HRS congress 2021

[2] Rillig A, Magnussen C, Ozga, Suling A, Brandes A, Breithardt G, Camm AJ, Crijns HJGM, Eckardt L, Elvan A, Goette A, Gulizia M, Haegeli LM, Heidbuchel H, Kuck KH, Ng GA, Szumowski L, van Gelder IC, Wegscheider K, Kirchhof P. Early rhythm control therapy in patients with heart failure. Circulation. 2021; (published ahead of print). DOI: 10.1161/CIRCULATIONAHA.121.056323

[3] Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, Fetsch T, van Gelder IC, Haase D, Haegeli LM, Hamann F, Heidbüchel H, Hindricks G, Kautzner J, Kuck K-H, Mont L, Ng GA, Rekosz J, Schön N, Schotten U, Suling A, Taggeselle J, Themistoclakis S, Vettorazzi E, Vardas P, Wegscheider K, Willems S, Crijns HJGM, Breithardt G, for the EAST–AFNET 4 trial investigators. Early rhythm control therapy in patients with atrial fibrillation. N Engl J Med 2020; 383:1305-1316.
DOI: 10.1056/NEJMoa2019422

Press Contact

Angelika Leute, PhD
Phone: +49 202 2623395

Follow us on Twitter @afnet_ev and hashtag #EASTtrial. @AndreasRillig

Funding: AFNET, BMBF, DZHK, EHRA, Deutsche Herzstiftung, Abbott, Sanofi


About the EAST – AFNET 4 trial

EAST – AFNET 4 is an investigator initiated trial (IIT) that compared two different treatment strategies in atrial fibrillation. The EAST – AFNET 4 trial tested whether an early, comprehensive rhythm control therapy can prevent adverse cardiovascular outcomes in patients with atrial fibrillation (AF) compared to usual care.

A total of 2789 patients with early AF (diagnosed less than a year ago) and at least two cardiovascular conditions (approximating a CHA₂DS₂-VASc score >=2) were enrolled by 135 sites in 11 countries during 2011 to 2016. Patients were randomized 1:1 to early rhythm control therapy or usual care, stratified by sites. Patients in both groups received guideline-recommended treatment for underlying cardiovascular conditions, anticoagulation, and rate control.

All patients in the early rhythm control group received antiarrhythmic drugs or catheter ablation after randomization (chosen by the local study teams). Rhythm control therapy was escalated with AF ablation and/or antiarrhythmic drugs when recurrent AF was documented clinically or by ECG, including monitoring with patient-operated ECG devices.

Patients in the usual care group were initially managed with rate control. Rhythm control therapy was only used to improve atrial fibrillation-related symptoms despite optimal rate control, following current guidelines.

About the Atrial Fibrillation NETwork (AFNET)

The Atrial Fibrillation NETwork is an interdisciplinary research network comprising scientists and physicians from hospitals and practices dedicated to improving the management of atrial fibrillation through coordinated research in Germany, Europe, and worldwide. Its main objective is to conduct high quality investigator-initiated clinical trials and registries on a national and international level. The AFNET continues the long-term activities of the network which has been funded by the German Federal Ministry of Research and Education over a decade. Since January 2015, specific projects and infrastructures of the AFNET are funded by the German Centre for Cardiovascular Research (DZHK).


The latest results of the EAST - AFNET 4  study will be presented at this year's HRS in Boston.

Early Rhythm Control Therapy In Patients With Atrial Fibrillation And Heart Failure (PD Dr. Andreas Rillig)
Live-Stream from the Heart Rhythm Society (HRS 2021), Boston, USA.
Friday, 30 July 2021
10:45am - 10:53am Eastern time / 4:45pm - 4:53pm CEST
More information


Early Rhythm Control for the Treatment of Atrial Fibrillation (Prof. Dr. Paulus Kirchhof)
Live-Stream from the Heart Rhythm Society (HRS 2021), Boston, USA.
Friday, 30 July 2021
1:30pm - 2:30pm Eastern time / 7:30pm - 8:30pm CEST
More information


Hot Topics: Practice Changing Trials in Atrial Fibrillation
EAST - AFNET 4 trial (Prof Dr. Paulus Kirchhof)
Friday, 30 July 2021
4:15pm - 4:27pm Eastern time / 10:15pm - 10:27pm CEST
On site, Exhibit Hall B2 - Booth 1389
More information

AFFECT-EU publication released

The desing paper of the AFFECT-EU project "Digital, risk-based screening for atrial fibrillation in the EU" has recently been published in the European Heart Journal.

The paper can be accessed here.


Our publication of the EAST-AFNET 4 results in the New England Journal of Medicine “Early Rhythm-Control Therapy in Patients with Atrial Fibrillation“ was read over 90.000 (and cited 48) times across all 5 continents. Two “Letters to the Editor” including the answers of the authors were recently released. Please read

Smart in OAC – AFNET 9 Enrollment of the 1st patient

The Smart in OAC – AFNET 9 study is testing whether unknown atrial fibrillation (AF) can be detected via an app and a monitoring bracelet. It is the objective to detect AF at an early stage using modern technologies. The number of newly detected, previously unknown episodes of atrial fibrillation and the effectivity of the program will be evaluated.

The “Kompetenznetz Vorhofflimmern e.V” (Atrial Fibrillation NETwork – AFNET) is pleased about the enrollment of the 1st patient in Poland and hopes for a good recruitment in all participating countries.