A synergistic impact of early rhythm control and lifestyle modification on the risk of stroke in patients with new-onset atrial fibrillation: a Korean nationwide population-based cohort study
Authors: Lee S R , Choi E K , Lee S W , Han K D , Oh S 
Published: October 2022

Abstract

Background
Early rhythm control therapy and lifestyle modification have both been associated with a lower risk of stroke in patients with atrial fibrillation (AF). Although guidelines have emphasized integrated care for patients with AF to improve clinical outcomes, the synergistic impact of early rhythm control therapy and lifestyle modification on the risk of stroke is unclear.

Purpose
To evaluate the impact of the combination of early rhythm control therapy and lifestyle modification on the risk of stroke

Methods
Based on data from the Korean National Health Insurance Service database, we included patients with new-onset AF between January 2009 and December 2016. Based on questionnaires from health checks, patients with ≥2 healthy lifestyle behaviors among quitting smoking, abstaining from alcohol, and performing regular exercise were defined as “healthy lifestyle” group. Patients who received rhythm control therapy within 2-year after new-onset AF were defined as the early rhythm control group. With a two-by-two factorial design, patients were categorized into 4 groups as follows: (i) those without early rhythm control and healthy lifestyle (group 1); (ii) those with a healthy lifestyle but without early rhythm control (group 2); (iii) those with early rhythm control but without healthy lifestyle (group 3); and (iv) those with both early rhythm control and healthy lifestyle (group 4). The primary outcome was stroke.

Results
Among a total of 208,662 patients, 46,972, 110,479, 15,133, and 36,078 patients were included in group 1, 2, 3, and 4, respectively. For the early rhythm control group, the mean duration from AF diagnosis to rhythm control therapy was 27±76 days. During a median follow-up of 4.2 years, 9905 patients had an incident stroke (incidence rate, 10.6 per 100 person-years). After multivariable adjustment, compared to group 1, group 2 (healthy lifestyle only) and group 3 (early rhythm control only) were associated with a lower risk of stroke (HR and 95% CI: 0.769, 0.728–0.881, and 0.774, 0.703–0.852, respectively) (Figure 1). Group 4 with early rhythm control and a healthy lifestyle had the lowest risk of stroke among all groups (HR 0.575, 95% CI 0.536–0.617 compared to group 1) (Figure 1). After propensity score (PS) weighting for group 2 and 4, additional early rhythm control based on healthy lifestyle was associated with a lowered risk of stroke by 22% (Figure 2). After PS weighting between groups 3 and 4, additional lifestyle modification based on early rhythm control was associated with a lowered risk of stroke by 27% (Figure 2).

Conclusion
In this large-scale observational cohort study, early rhythm control therapy and healthy lifestyle behavior might reduce the risk of stroke in patients with new-onset AF, consistent with the results from recent randomized clinical trials. Furthermore, implementing both early rhythm control therapy and a healthy lifestyle could synergize stroke prevention in these populations.

Funding Acknowledgement
Type of funding sources: None.