I Told You I Was Right, Sinus Rhythm is King

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Featured is the presentation entitled “I Told You I Was Right, Sinus Rhythm is King” from Session 1 of WAFib 2023.

Let me take you back. This is what started a lot of the controversy. Anyone who has followed my writings and lectures on this knows that I've been pretty bullish on sinus rhythm. I felt this trial was very flawed. I refused to participate in it. The organizers of it called me the day before the meeting when it was going to be a late-breaker and said, “just give us a chance to get everything out before you get to the microphone.” I agreed to but said “just be fair,” because they told me what the data were. I said, “this is a neutral trial. Don't start pushing rate control that you guys like.” But of course, they started pushing rate control. I think this trial did a lot of damage to a lot of patients. If you go back to the famous speech by Winston Churchill, “From Stettin in the Baltic to Trieste in the Adriatic, an iron curtain has descended across the continent.” That's where the term “the iron curtain” came from, and no, he actually didn't give the speech in London. He was in the United States when he gave this speech. So, here's my version of it: “From Honolulu in the Pacific to Athens in the Aegean, the AFFIRM mismessage curtain has descended across Western medicine.” I think it has really hurt a lot of patients because it's a cop-out for many people, like “Okay, I can use AFFIRM data.” A lot of people need sinus and they never got a chance. So, let's review some really wonderful work from Jared Bunch. The endpoint has always been stroke, as if that's the only thing that happens in the brain. I saw Mellanie True Hills here today, and she has been an incredible proponent of preserving the brain, which she and I have been doing for years. She always talks about fuzzy brains and things she hears from patients, and it is true. A lot of people just don't feel great when they're in atrial fibrillation (AFib). Here is a nice study showing that folks with AFib had a greater chance of Alzheimer's, senile dementia, and even vascular dementia. With ablation, they did better. It was intriguing. It wasn't a prospective study, but intriguing. There is also data from Gaita's lab in Italy showing if you do cognitive function evaluations in patients, the higher number the better. They did multiple tests, none of which I know anything about, frankly, but they're all different cognitive tests for mental function. Except for 1 of the 5, the patients with AFib did worse than others, so there's something going on. I think we're finally getting a little physiology into this. There is a recent paper from Jared Bunch looking at reserve of flow in the brain. This in a dog study, you can see on panel A on the left, the red is increased blood flow, and diamox is given on the right. You can see that it increases. Then, with pacing, he put animals into AFib for a while, and looked at this. You can see that even at 6 months, things get better but you're never back to where you were. So, something's going on other than stroke that we have to be mindful of. Is this what you want if you don't have to have it? I would say no. Then this trial came about, and I also didn't participate, and I also didn't think it was a good trial. I thought that there was way too much crossover, for example, in the patients who are supposed to be rate control only. If you look at when they're in AFib, 40% of the time, they're in sinus, and the patients who are in sinus a lot of the times are in AFib. So, I thought it was a flawed trial. As a clinician with a large practice, I would see patient after patient where they weren't doing as well in heart failure, then you restore sinus rhythm and they're suddenly better. I think every clinician has seen that. Now, I know one swallow does not a summer make, so I'm not going to say that should change your mind, but you surely should change your mind after you listen to the second presentation today. If you look at other data, again, not randomized trials, but hints that something bad is going on in the ASSERT trial, if you slipped into greater than 24 hours of AFib, you had a much higher risk of heart failure. Then, of course, you have the classic paper from Dr Marrouche and colleagues that has already been shown here, the CASTLE study showing a statistically randomized prospective study where patients do better in sinus rhythm. Actually, Pierre is up here with me. The first hint I had to this, Pierre, was your paper that you all wrote in the New England Journal of Medicine. Since you're on the panel, it was an eye-opener to me because the concept back then was if you have good rate control, you're probably okay. But I remember reading in your paper that these patients all had good rate control, and then you went and ablated them, and the ejection fractions went up. That was the first eye-opener to me that there's something else going on here, not surprising it came from the Bordeaux group, but that was an extremely important paper and one of the first messages that we all should have listened to. So, remember, a lot of people are still not getting folks into sinus rhythm. Why do you need sinus rhythm? That was the human cry out there. I remember being on a panel with Mellanie and someone asked, “What do you care about quality of life?” How many patients come to you and say, “I was thinking I'd like to live 2 years longer. Will you ablate me?” I mean, that's not why they come to you. They come to you because they don't feel good. That's why they come to you. Improving quality of life is a good thing and sinus rhythm improves quality of life, study after study. That's not a bad thing. Then, of course, you have the EAST study. I know this will be discussed in more detail later. But the bottom line in the EAST study is if you get the people early and get them in sinus rhythm, preliminary data says they do better. So, this is the reason. This is from an editorial I wrote. I deal with this a lot in the office about a bridge to the future. I try to explain patients, even though they feel well now, and many of them do, I understand. Everyone says they don't know they're not feeling well. That's true for some people without a doubt. But there are others you cardiovert and they honestly tell you they don't feel any different. Then, the discussion must be, “Do you want to be in AFib the rest of your life?” That's when you have to be really upfront and have a discussion with the patient to explain things other than mortality, such as how they are going to feel and sinus rhythm if they slip into heart failure. If you missed this, which a lot of AFib patients did, many of us who've been around a while see people who've been in AFib for 3-6 years, and it's just too late. We all know that. Sana Al-Khatib, who is going to be the future president of the Heart Rhythm Society, requested that I write this article for Circulation. I'll just read the last paragraph to end my talk: “The benefits of sinus rhythm should be discussed with the patient when AFib is first diagnosed.” Not 12 years later, okay? “Rhythm control is preferred.” I think the data are fairly clear on this in patients who have heart failure, and for me, I think the data are fairly clear for most people under 70. The final decision obviously should be a shared decision, but this is why patients need at least one trip to an electrophysiologist who should know the data and can have that discussion. They don't have to be followed necessarily, but I think the patient needs to get the appropriate data and make a decision. So, Nassir, once again, thank you for putting on the meeting and for having me here for 16 years. Thank you very much.

The transcripts have been edited for clarity and length.