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Key AF takeaways from ESC 2020

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The virtual European Society of Cardiology (ESC) Congress 2020 (29 August – 1 September) saw several atrial fibrillation (AF) studies presented, including the much-discussed EAST-AFNET 4 trial.1 This report outlines the key findings of these studies. 


According to this study, which was published in The New England Journal of Medicine as well as presented at the ESC 2020, early rhythm control (with anti-arrhythmic drugs or ablation) in patients with newly diagnosed AF (≤1 year before enrolment) is associated with a lower risk of cardiovascular conditions than is standard care. At present, rhythm control treatment is typically delayed unless patients have persistent symptoms on otherwise effective rate control. 

In the New England Journal of Medicine, principal investigator Paulus Kirchof (University Medical Center Hamburg-Eppendorf, Hamburg, Germany) and others noted that early rhythm control was associated with more adverse events than standard care. However, they added: “The incidence of the overall safety outcomes events was similar in the two groups”. Furthermore, according to Dr Shouvik Haldar (Royal Brompton & Harefield NHS Foundation Trust, London UK), if the data is studied more carefully, then it becomes clear that the safety endpoint was a composite of stroke, death, and specific adverse effects from rhythm control. Early rhythm control was better with respect to stroke and death, but serious adverse events due to rhythm control strongly was better for standard care. Dr Haldar noted that EAST-AFNET 4 “shows that an early rhythm-control strategy with excellent patient compliance with important background with may improve outcomes compared with a strategy of rate control albeit with the potential for serious adverse effects”. 

Kirchof et al concluded that the results of EAST-AFNET 4 are “relevant to decisions regarding rhythm-control therapy in patients with early atrial fibrillation”. 


According to Dr Dipak Kotecha (University Hospitals Birmingham, Birmingham, UK) and colleagues, the results of the RATE-AF trial show that digoxin should be considered as a first-line approach for rate control in patients with permanent atrial fibrillation (AF).2 In the study, 160 patients (aged 60 or older) with permanent AF and breathlessness were randomised to digoxin or bisoprolol. The primary outcome was quality of life related to physical function at six months, with key secondary outcomes being heart rate, modified European Heart Rhythm Association (mEHRA) symptom classification and NTproBNP at six and 12 months and other adverse clinical events at 12 months. 

There were no significant differences between groups in the primary endpoint. However, at 12 months, digoxin was associated with some improvement in quality of life and with greater reductions in New York Heart Association Class (NYHA) and NT-proBNP. Cardiac Rhythm News reports that Dr Kotecha concluded: “The RATE-AF trial has demonstrated that digoxin therapy in older patients with permanent AF and symptoms of heart failure has a similar effect as beta blockers on both heart rate and the physical components of quality of life. However, digoxin had a considerably better symptom improvement, a reduction in natriuretic peptides and much lower rates of adverse events, without any compromise of left ventricular reduction.”

Additionally, published in Cardiology, another study from the RATE-AF investigators found that the impact of comorbidities is poorly appreciated in the context of AF.3 They also found that there is considerable variability in quality of life that requires both generic and AF-specific assessment. Investigators Jacqueline Jones (Patient and Public Involvement Team, RATE-AF trial, Birmingham, UK) and colleagues, including AF Association CEO and founder Trudie Lobban MBE, commented: “Improvement in QoL should direct the appraisal, and reappraisal, of treatment decisions for patients with permanent AF.”


The CASA-AF randomised controlled trial found that single procedure thoracoscopic single ablation was not superior to catheter ablation for treating long-standing persistent AF.4 Furthermore, it showed that catheter ablation provided greater symptom improvement and accrued significantly more quality-adjust life years. Coinciding with its presentation at the ESC 2020, CASA-AF was also published in the European Heart Journal.

Principal investigator Dr Haldar, who was recently announced as the new A-A HRC programme director, said: “CASA-AF was a multicentre, randomised control trial designed to answer whether thoracoscopic surgical ablation was superior to the more established catheter ablation procedure in patients with long-standing persistent AF. These patients are notoriously difficult to treat as they are generally refractory to antiarrhythmic drugs and electrical cardioversion. We sought to determine recurrence of AF using an implantable loop recorder, which allows for continuous cardiac monitoring and provides a thorough evaluation of arrhythmia recurrence including burden of arrhythmia assessment. To provide a holistic answer, we also investigated the change in patients’ symptoms and quality of life as well as performing an in-trial health economic assessment.

“Our results showed that thoracoscopic surgical ablation was not better than catheter ablation in terms of achieving freedom from AF recurrence. Absolute freedom for arrhythmia in both groups were similar at just under 30%. However, it is important to appreciate that there was a 75% reduction in AF burden in around 70% of patients in both groups. This is an excellent result for both groups, and it is clinically very relevant from the patient perspective. Overall, catheter ablation fared better than surgery for symptoms, quality of life improvements in symptoms and cost-effectiveness. Therefore, from our perspective [as investigators], we think surgical ablation is not ready to be used as a mainstream therapeutic option yet and we would still recommend catheter ablation as the first line intervention for symptomatic long-standing persistent AF patients.”

Arrhythmia Alliance president Professor John Camm (St George's University of London, London, UK) stated: “Randomisation between two very different approaches to therapy, one involving cardiac surgery, is such a difficult undertaking but has been successfully completed under the leadership of the team at the Royal Brompton & Harefield Hospital. This robust study, involving ‘state of the art technology’ clearly demonstrated that atrial fibrillation is equally well treated by the invasive electrophysiologist and the surgeon.”

Trudie Lobban MBE, CEO and Founder of the AF Association, was one of the CASA-AF investigators. For more information on how the AF Association can help clinicians, visit our “For Clinicians” page.


The IMPACT-AFib trial found that education on stroke prevention in AF for patients and their healthcare providers did not increase the use of anticoagulants.5 Dr Sean Pokorney (Duke University, Durham, USA) and colleagues randomised 47,333 patients — aged 30 years and older with a guideline-based indication for oral anticoagulation into the study — to educational intervention or usual care (control group). In the intervention group, patients and their healthcare providers received one mailing at the start of the trial. At one year, 9.9% (2,328) of patients in the intervention group and 9.8% (2,330) in the control group had started on oral anticoagulation over the course of the 12-month trial (the primary endpoint). The adjusted odds ratio was 1.01 (95% confidence interval 0.95–1.07).

Dr Pokorney commented: “Among a population with a guideline indication for oral anticoagulant[s] for stroke prevention with atrial fibrillation, there was no statistically significant difference in rates of oral anticoagulant initiation at one year with a single education intervention.”

More AF content at HRC 2020

The virtual Arrhythmia Alliance (A-A) Heart Rhythm Congress 2020 (HRC2020) has several presentations on AF, including a talk by Professor Paulus Kirchof on the results of EAST-AFNET 4 (as part of the A-A Symposia). Not yet registered? Register before the end of 2020 to receive FREE 12-month access to all content.


  1. Kirchof P, Camm JA, Goette A, et al. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med 2020; 383 (14): 1305–16.

  2. Date W. ESC 2020 Congress: Digoxin found to be favourable in rate control for permanent AF patients. Cardiac Rhythm News 2020.

  3. Jones J, Stanbury M, Haynes S, et al. Importance and assessment of quality of life in symptomatic permanent atrial fibrillation: Patient focus groups from the RATE-AF trial. Cardiology 2020. Epub. 

  4. Haldar S, Khan HR, Boyalla V, et al. Catheter ablation vs. thoracoscopic surgical ablation in long-standing persistent atrial fibrillation: CASA-AF randomized controlled trial. European Heart J 2020. Epub.

  5. ESC Press Office. Educational mailing fails to improve medication use in patients with atrial fibrillation. ESC 2020.


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