Early Rhythm Control May Be Cost-Effective in Atrial Fibrillation Care

A cost-effectiveness analysis of the EAST – AFNET 4 trial indicated the health benefits of early rhythm control come at reasonable additional costs compared to usual care.

Professor Paulus Kirchhof │ LinkedIn

Professor Paulus Kirchhof

Courtesy of LinkedIn

A cost-effective analysis based on EAST-AFNET 4 trial revealed the health benefits of early rhythm control in patients with atrial fibrillation (AF) come at reasonable additional costs based on incremental cost-effectiveness ratio (ICER) point estimates.1

After accounting for statistical uncertainty, data indicated the high probability of the cost-effectiveness of early rhythm control at a willingness-to-pay value of ≥€55 000 per additional life year or year without a primary outcome (cardiovascular death, stroke, or hospitalization for heart failure or acute coronary syndrome).

“The health benefits of early rhythm control come at reasonable additional costs as indicated by our analysis of the EAST – AFNET 4 study data for Germany,” said principal investigator Professor Paulus Kirchhof, Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf.2 “The added cost is comparable to the cost of other therapies reducing outcomes, and within typical ranges of acceptable payments in Germany.”

Previously, the EAST–AFNET 4 trial found that systematic early rhythm control therapy reduced the composite primary outcome by 20% compared with usual care in 2,789 patients with early AF over a 5-year follow-up. Kirchhof and colleagues noted a concern after reporting results was whether additional treatment would add a reasonable or undue financial burden to healthcare systems. To ensure a consistent and realistic costing approach, investigators restricted the cost-effective analysis to data from the Germany study sites, or 1664 of the 2789 trial participants.

The cost-effectiveness analysis was conducted from a Germany healthcare payer’s perspective and was restricted to hospitalization, as the main driver of AF-related costs, and medication costs. Effect measures consisted of the time to the occurrence of a primary outcome and the time survived in the observation period. Investigators set the time horizon for the analysis to 6 years and calculated ICERs as the difference in mean costs and effects between early rhythm control and usual care.

The 1664 participants were equally randomized (n = 832 each) to early rhythm control and usual care. Over the follow-up period, investigators noted fewer first primary outcome events (210 vs. 255) and a lower number of deaths (117 vs. 139) occurred in the early rhythm control compared to the usual care group.

The adjusted analysis indicated early rhythm control was associated with non-significantly higher mean total costs ([+€1924, 95% confidence interval [CI], −€399 to €4246), as well as a significantly longer mean time to the occurrence of a primary outcome event (+0.18 years) and a non-significantly longer mean survival time (+0.09 years).

Data showed the ICER was €10,638 per additional year without a primary outcome and €22,536 per life year gained. Moreover, the uncertainty analysis revealed the probability of early rhythm control being cost-effective compared to usual care was ≥95% and ≥80% at a willingness-to-pay value of ≥€55,000 per additional year without a primary outcome or life year gained, respectively.

Based on the identified point estimates and common threshold recommendations, Kirchhof and colleagues indicated that early rhythm control could be considered economically attractive, despite the cost per quality-adjusted life-year (QALY) likely to be higher than recommended.

“Future studies examining the cost–effectiveness of early rhythm control in other countries, in subgroups with higher benefit from rhythm control therapy, or the cost-effectiveness of different modes of early rhythm control are warranted,” the team concluded.2


  1. Sophie Gottschalk, Shinwan Kany, Hans-Helmut König, Harry JGM Crijns, Panos Vardas, A John Camm, Karl Wegscheider, Andreas Metzner, Andreas Rillig, Paulus Kirchhof, Judith Dams, Cost-effectiveness of early rhythm control vs. usual care in atrial fibrillation care: an analysis based on data from the EAST-AFNET 4 trial, EP Europace, 2023;, euad051, https://doi.org/10.1093/europace/euad051
  2. Escardio. (2023, March 25). Is early rhythm control in atrial fibrillation care cost-effective? EurekAlert! Retrieved March 27, 2023, from https://www.eurekalert.org/news-releases/983895
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