Cluster-specific predictors of early rhythm control in contemporary European cohort of patients with atrial fibrillation: The EHRA-PATHS Project

Abstract Background Early rhythm control (ERC) using antiarrhytmic drugs, electrical cardioversion or catheter ablation for AF within a year from first diagnosis of atrial fibrillation (AF) has been shown to reduce the risk of major adverse outcomes compared to usual care, and the effects of ERC have been suggested to be consistent across all AF subgroups with different risk profiles. We aimed to identify cluster-specific predictors of ERC in pre-defined AF clusters in contemporary European EHRA-PATHS AF cohort. Methods The EHRA-PATHS AF cohort was derived from the three prospective EurObservational Research Programme (EORP) AF registries - General Pilot, General Long-term, and AF III registry. A two-step cluster analysis was performed. A hierarchical cluster analysis with 18 variables was used to identify the optimal number of clusters, followed by a K-means cluster analysis to determine variable cluster association. Cluster-specific predictors of ERC were identified using univariate and multivariate logistic regression analyses. Results Of 18,799 patients, AF was diagnosed within 1 year in 8088 (43.0%), and 3913/8088 patients (48.4%) were treated with ERC. Among the three clusters - Cluster 1 (younger healthier AF patients) compared with Cluster 2 (Elderly with less comorbidity, mostly non-cardiovascular) and Cluster 3 (Elderly with more comorbidity, mostly cardiovascular), see Table, ERC was significantly more often used in Cluster 1 compared with Cluster 2 and Cluster 3 (both P<0.001), and in Cluster 2 compared with Cluster 3. Cluster-specific multivariable predictors of ERC are shown in Table. In all three clusters, asymptomatic AF (EHRA score I) and Northern Europe residence were inversely associated with ERC, while Western Europe residence was positively associated with ERC in Cluster 2 and 3. In Cluster 1, low stroke risk and hypertension were positively associated with ERC, while dilated left atrium (LA) and reduced left ventricular ejection fraction (LV EF) were negative predictors of ERC. In Cluster 2, age ≥80 years, enlarged LA, and CHA2DS2-VASc ≥2 for males and ≥3 for females were negatively associated with ERC. In Cluster 3, age ≥75 years, cardiomyopathy, liver disease, dementia and reduced LV EF were negative predictors of ERC. Conclusion Our study of a large European AF cohort showed that likelihood for ERC was greater in younger and healthier AF patients, as well as in elderly from Western Europe, while ERC was significantly less likely with increasing age and comorbidity (especially cardiovascular diseases). These findings likely reflect the lack of high-quality evidence supporting aggressive ERC in high-risk patients with AF. With increasing body of evidence favouring ERC such patients, a shift towards less selective consideration of ERC in daily practice may be expected.