New-Onset AF Linked to Acute Decompensated Heart Failure and Higher Maintenance of Sinus Rhythm

The American College of Cardiology/American Heart Association/European Society of Cardiology 2006 Guidelines for the management of patients with atrial fibrillation emphasized that clinicians should recognize the first detected episode of atrial fibrillation. However, the 2014 guidelines did not include this mandate to recognize a first episode, suggesting a lack of data regarding specific treatment for patients with the first detected episode of AF. Further, patients with new onset AF are significantly less likely to get anticoagulated than patients with prior atrial fibrillation, despite the presence of stroke risk factors.

Abdulla A. Damluji, M.D., M.P.H., a 3rd year cardiology fellow, and Raul D. Mitrani, M.D., associate professor of medicine and Director of Clinical Cardiac Electrophysiology Service at University of Miami Miller School of Medicine, and their colleagues report that there are no mortality differences between new-onset versus prior history of atrial fibrillation on more than 7 years of follow-up in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial (NCT00000556). The investigators discovered that patients with new-onset atrial fibrillation are more likely to present with acute decompensated heart failure, which represents a marker of underlying hemodynamic and structural abnormalities.

In their study published online April 24 in the American Heart Journal, the researchers evaluated whether patients with new-onset atrial fibrillation were more likely to remain in normal sinus rhythm (NSR), compared with patients with prior history of atrial fibrillation treated with rate or rhythm control strategies.

“Within the rate-control group, there was no significant difference in the time to first recurrence of atrial fibrillation between patients with new-onset versus those with a prior history of AF,” said Mitrani. In contrast, patients with new-onset AF treated with a rhythm-control strategy were 21 percent more likely to remain in NSR during follow-up compared to patients with a prior history of AF, after adjusting for confounders.

Mitrani said, “To our knowledge, this is the first report to evaluate the response to anti-arrhythmic medications in patients with new-onset atrial fibrillation compared to those with established history of AF.”

The findings from this study are consistent with the notion that atrial fibrillation is a progressive disease and that anti-arrhythmic drug therapy is more likely to be effective early in the disease course rather than later. The study further suggests the utility in a larger clinical study to evaluate the effects of early treatment with either anti-arrhythmic or catheter-based therapies for patients with new-onset AF on important clinical outcomes and disease progression.

Lastly, the investigators discovered no crude differences in the rate of ischemic stroke between patients with new onset versus prior history of AF regardless of the treatment strategy. These results reinforce the importance of anticoagulation in patients after their first episode if they meet the guideline criteria for anticoagulation. These observations are important and relevant to practicing clinicians managing patients with new-onset atrial fibrillation who may still be reluctant to prescribe anticoagulation after a single episode of AF.

Other scientists who contributed to the study include Mohammed S. Al-Damluji, M.D., M.P.H. from Yale University School of Medicine; cardiovascular resident George R. Marzouka, M.D.; James O. Coffey, M.D., assistant professor of medicine; Juan F. Viles-Gonzalez, M.D., assistant professor of medicine; Mauricio G. Cohen, M.D., associate professor of medicine; and Robert J. Myerburg, M.D., professor of medicine, all from the Miller School of Medicine; Mauro Moscucci, M.D., M.B.A., chair of medicine at Sinai Hospital in Baltimore.

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