Real-world evidence of early rhythm control in patients with atrial fibrillation: A systematic review and meta-analysis

The favorable benefits of early rhythm control (ERC) therapy in newly diagnosed patients with atrial fibrillation (AF) have been demonstrated in the EAST-AFNET 4 trial. However, the generalizability and applicability of ERC in real-world clinical settings remain inconclusive. We conducted a systematic search of the PubMed and Embase databases to identify observational studies published between January 2020 and February 2024 that focused on real-world evidence pertaining to ERC. The effectiveness and safety outcomes in our study were analogous to those evaluated in the EAST-AFNET 4 trial. A total of 4 observational studies that fulfilled the inclusion criteria of EAST-AFNET 4 were included, involving 130,970 patients with AF, 30.7% of whom received ERC therapy. In our pooled analysis using the fixed-effects model, compared with rate control, ERC significantly decreased the occurrence risk of the primary composite outcome (hazard ratio [HR] 0.86, 95% confidence interval[CI] 0.82–0.91), cardiovascular death (HR 0.87, 95% CI 0.78–0.98), stroke (HR 0.80, 95% CI 0.73–0.87), and hospitalization with worsening heart failure (HR 0.91, 95% CI 0.84–0.99) or acute coronary syndrome (HR 0.72, 95% CI 0.59–0.87). In terms of safety outcomes, there were no differences in the composite safety outcome (HR 1.00, 95% CI 0.95–1.05) and all-cause death (HR 0.93, 95% CI 0.82–1.06) between the two studied groups. ERC therapy showed favorable effectiveness outcomes compared with rate control, whereas the safety outcomes between the two therapeutic strategies did not differ significantly, supporting the benefits of ERC therapy over rate control in selected real-world patients with AF. Registration: The study protocol was registered to PROSPERO (CRD42023443569). •EAST-AFNET4 trial demonstrates early rhythm control's favorable benefits in newly diagnosed AF patients.•In real-world settings, early rhythm control shows superior effectiveness compared to rate control for AF patients.•Early rhythm control and rate control therapies do not differ significantly in safety outcomes in real-world AF patients.