Ранняя ритм-контроль снижает риски у пациентов с фибрилляцией предсердий и хронической болезнью почек

Early rhythm control reduces the composite risk for cardiovascular death, stroke, heart failure hospitalization, and acute coronary syndrome compared with usual care using rate-control drugs among patients with recent atrial fibrillation (AFib) and mild to moderate chronic kidney disease (CKD). The Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) was an investigator-initiated, international, randomized, open-label trial (ClinicalTrials.gov, NCT01288352). Investigators randomly assigned patients (N=2789) with recent AFib to receive early rhythm control (n=1395) or usual care (n=1394). In this predefined secondary analysis, the safety and efficacy of early rhythm control was assessed on the basis of CKD status among patients with sufficient glomerular filtration rate (GFR) data. The CKD group comprised 23% of the cohort. Among the CKD group, more than 70% of patients had a baseline eGFR of 45-59 mL/min/1.73 m2, whereas 27% had an eGFR of 15 to 45 mL/min/1.73 m2 (dialysis population was excluded). Patients with vs without CKD had more recent AFib diagnosis and higher CHA2DS2 -VASc-Score. They were also older, more often female, and exhibited more cognitive impairment. The primary endpoint was the composite of cardiovascular death, stroke, hospitalization for worsening heart failure, and acute coronary syndrome (ACS). The primary composite outcome occurred in a lower proportion of patients treated with early rhythm control compared with usual care, whether they had CKD (5.8% vs 8.5% per 100 person-years) or not (3.4% vs 4.1% per 100 person-years), Paulus Kirchhof, MD, of the University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, and colleagues reported in the Journal of the American College of Cardiology. No significant interactions were observed by CKD status for any of the individual components of the composite outcome. Early rhythm control was more effective at preventing AFib recurrence in patients with CKD than without (hazard ratio [HR], 0.65 vs 0.82; P =.036), respectively. Early rhythm control did not increase safety events compared with usual care. However, patients with vs without CKD receiving early rhythm control had a higher rate of the primary safety endpoint: 27.2% vs 13.8%, respectively. No significant change in GFR was observed from baseline to 2 years in any group. This sub-study was limited by the imbalanced cohort sizes, and results should be regarded as hypothesis-generating. “[Early rhythm control] effectively and safely reduced a composite outcome of death, stroke, hospitalization for heart failure, and acute coronary syndrome with and without CKD…” Dr Kirchhof’s team wrote. “These findings support the use of [early rhythm control] in patients with AFib and CKD, while highlighting the need for further dedicated studies in this field.” In an accompanying editorial, Poojita Shivamurthy, MD, and Rajat Deo, MD, MTR, of Penn Medicine, University of Pennsylvania in Philadelphia, Pennsylvania, pointed out that few patients had advanced CKD and none were on dialysis. In subgroup analysis, early rhythm control was not significantly more effective than usual care among this subset of patients with the most severe CKD and it led to a higher safety event rate. “This treatment paradigm continues to evolve as we can now advocate for a rhythm-control strategy for AFib in patients with mild-to-moderate CKD,” the editorialists wrote. However, to understand the role of rhythm control in advanced CKD, they advocated for rigorous analytic methods that account for the competing risk of noncardiovascular events and a net clinical benefit assessment in future studies. New-onset atrial fibrillation may accelerate kidney function decline in adults aged 35 to 59 years, according to a separate study published in JAMA Network Open. Using a nationwide Japanese database, the investigators matched 23,510 adults with new-onset atrial fibrillation to 117,550 healthy adults serving as a control group. The vast majority had a baseline eGFR above 60 mL/min/1.73 m2. The annual rate of eGFR decline was 1.23 mL/min/1.73 m2 in the AFib group compared with 0.94 mL/min/1.73 m2 in the control group — a significant difference. Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. References: Schenker N, Borof K, Goette A, et al. Effectiveness and safety of early rhythm control in patients with atrial fibrillation and chronic kidney disease. J Am Coll Cardiol. 2026:S0735-1097(26)06010-9. doi:10.1016/j.jacc.2026.03.087 Shivamurthy P, Deo R. Atrial fibrillation and rhythm control: another win in chronic kidney disease. J Am Coll Cardiol. 2026:S0735-1097(26)06205-4. doi:10.1016/j.jacc.2026.04.006 Mori Y, Hirano K, Ikenoue T, Kobayashi A, Yanagita M, Fukuma S. New-onset atrial fibrillation and accelerated kidney function decline in working-age adults. JAMA Netw Open. 9(5):e2612823. doi:10.1001/jamanetworkopen.2026.12823