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Press release

On 12 and 13 September international experts in atrial fibrillation come together in Münster, Germany, to take part in the 9^th AFNET/EHRA consensus conference. “Longer and better lives for patients with atrial fibrillation” is the pronounced intention of the two-day expert meeting which is jointly organized by the German Atrial Fibrillation Network (AFNET) and the European Heart Rhythm Association (EHRA) every two years.

Atrial fibrillation (AF) is the most common heart arrhythmia and a growing health problem in an aging society. It affects several million people in Europe and worldwide.

Prof. Paulus Kirchhof, Hamburg, Germany, one of the four chairpersons of the conference and board member of AFNET, explains the background of the expert meeting: “Despite improved treatment options AF patients still suffer strokes, heart failure, and premature death. There are various approaches to optimize care for AF patients. We set out to bring these approaches together. The AFNET/EHRA consensus conference provides a high-level expert forum to discuss recent advances in AF diagnosis and therapy.”  

The participating scientists will discuss new results in AF screening, the therapeutic impact of rare atrial arrhythmias picked up by implanted devices and consumer electronics, the role of early rhythm control, new data on the interaction of comorbidities with AF and AF management, new technologies for AF detection and management, the role of pacing and devices in the management of AF and heart failure, as well as new trial results from the main 2023 congresses.

Participants of the 9^th AFNET/EHRA Consensus Conference come from Europe, USA, Canada, and Australia. The meeting is chaired by four cardiologists: Prof. Andreas Goette, Paderborn, Germany, and Prof. Paulus Kirchhof, Hamburg, Germany, both from AFNET, and Prof. Helmut Pürerfellner, Linz, Austria, and Prof. Isabell van Gelder, Groningen, Netherlands, both from EHRA.

This is already the 9^th meeting of its kind. Since 2007, AFNET and EHRA organize biennial joint conferences in which international AF experts pool their knowledge. After detailed discussions, the scientists publish their results in a consensus report.

Prof. Goette summarizes the experts` aim: “During the conference, we will jointly develop recommendations for better AF management, and we will summarize them afterwards in a position paper. We hope our results will be integrated into the upcoming treatment guidelines of the European Society of Cardiology (ESC) next year.”

The conference is organized and co-financed by AFNET – celebrating 20 years anniversary in 2023 – and EHRA with additional financial support from MAESTRIA which is funded under European Union's (EU) Horizon 2020 research and innovation program (grant number 965286).

About AFNET

The Atrial Fibrillation NETwork is an interdisciplinary research network comprising scientists and physicians from hospitals and practices dedicated to improving the management of atrial fibrillation through coordinated research in Germany, Europe, and worldwide. Its main objective is to conduct high quality investigator-initiated clinical trials and registries on a national and international level as well as translational research projects. The AFNET continues the long-term activities of the network which has been funded by the German Federal Ministry of Research and Education over a decade. Since January 2015, specific projects and infrastructures of the AFNET are funded by the German Centre for Cardiovascular Research (DZHK), and some projects by EU research grants. AFNET has long expertise in the management of atrial fibrillation, but also provides support for work in other fields informing cardiovascular care. The results of 20 years of clinical and translational research improved the lives of patients with cardiovascular diseases and influenced treatment guidelines.

www.af-net.eu

Press Contact

Angelika Leute, PhD

Phone: +49 202 2623395

a.leute@t-online.de

Press release

The clinical trial NOAH – AFNET 6 conducted by the German Atrial Fibrillation Network (AFNET), Münster, Germany, revealed: In patients with atrial high rate episodes (AHRE), but without ECG-documented atrial fibrillation (AF), oral anticoagulation increases bleeding without reducing strokes. Stroke rate was low in patients with AHRE with and without oral anticoagulation. The results were presented today at the annual congress of the European Society of Cardiology (ESC) in Amsterdam and published in the New England Journal of Medicine (1).

Atrial high-rate episodes are short and rare atrial arrhythmias that resemble atrial fibrillation detected by implanted pacemakers, defibrillators, and loop recorders that enable long-term monitoring of heart rhythm. AHRE are found in 10-30% of patients with implanted devices (2). AHRE episodes resemble atrial fibrillation. Therefore, patients with AHRE are often offered treatment with blood thinners (oral anticoagulation) without ECG-documented atrial fibrillation. So far, the efficacy and safety of oral anticoagulation has never been tested in patients with AHRE (2,3).

The Non vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes trial (NOAH-AFNET 6) compared the anticoagulant edoxaban to placebo in an international investigator-initiated, randomized, double-blind, double-dummy outcomes trial. NOAH-AFNET 6 randomized patients with AHRE episodes lasting 6 minutes or longer detected by implantable devices, and aged 65 years or more with at least one additional stroke risk factor of heart failure, hypertension, diabetes, prior stroke or transient ischaemic attack, vascular disease, or age from 75 years. This patient population was outside of the approved indication of edoxaban.

Prof. Paulus Kirchhof, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany, principal investigator of NOAH – AFNET 6 explained the background of the trial: “Whether anticoagulants can prevent strokes in patients with device-detected AHRE, was not known. Although AHRE resemble atrial fibrillation, NOAH – AFNET 6 demonstrates that patients with AHRE are better managed without anticoagulation.”

Between 2016 and 2022, NOAH – AFNET 6 enrolled 2536 patients in 206 sites across 18 European countries. Patients were randomly allocated in a 1:1 fashion to anticoagulation or no anticoagulation. Anticoagulation consisted of edoxaban in the dose approved for stroke prevention in atrial fibrillation (60 mg once daily, reduced to 30 mg once daily according to approved dose reduction criteria for stroke prevention in atrial fibrillation). No anticoagulation consisted of placebo containing no active compound or aspirin 100 mg once daily in patients with an indication for antiplatelet therapy (3).

The analysis included the data of 2536 patients aged 78 on average. 37% were women. The patients had additional stroke risk factors (median CHA2DS2-VASc score 4.0±1.3) and a median AHRE duration of 2.8 hours. All patients were followed until the end of the trial.

In September 2022 it was decided to orderly terminate the trial after enrolment of all patients due to the observed trend towards futility for efficacy combined with expected safety concerns. The analysis of the full data confirms this:

Stroke, systemic embolism, or cardiovascular death occurred in 83 patients in the anticoagulation group and 101 patients in the no anticoagulation group (stroke: 0.9% versus 1.1% per year, systemic embolism: 0.5% versus 1.1% per year, cardiovascular death: 2.0% versus 2.2% per year). This means no significant difference between treatment groups (HR 0.81 [0.6;1.08], p=0.15).

A major bleeding event or death occurred in 149 patients in the anticoagulation group (5.9% per year) and in 114 patients in the no anticoagulation group (4.5% per year), thus more often in patients randomized to anticoagulation (HR 1.3 [1.02;1.67], p=0.03). This was mainly driven by a doubled rate of major bleeding (2.1% versus 1.0% per year), a known side effect of all anticoagulants.

Prof. Kirchhof commented: “As expected, anticoagulation increased bleeding. The low stroke rate with and without anticoagulation was unexpected. The results of NOAH – AFNET 6 clearly suggest to demand ECG documentation of atrial fibrillation prior to initiation of oral anticoagulation. The results also call for randomized trials evaluating anticoagulation in people in whom smartwatches detect arrhythmias that resemble atrial fibrillation.”

Prof. Andreas Goette, St. Vincenz Hospital, Paderborn, Germany, NOAH – AFNET 6 sponsor representative, concluded: “Our results underpin evidence from other trials which indicated that in patients with AHRE anticoagulants may not be as effective in preventing strokes as previously thought. Further research is needed to identify patients with AHRE at high stroke risk and to find the optimal treatment for these persons.”

NOAH – AFNET 6 was financially supported by Daiichi Sankyo Europe and the German Centre for Cardiovascular Research (DZHK). The sponsor of the investigator-initiated trial is AFNET.

References

(1) Kirchhof P et al. Anticoagulation with Edoxaban in Patients with Atrial High Rate Episodes. NEJM 25 August 2023. doi: 10.1056/NEJMoa2303062

(2) Toennis T et al. The influence of atrial high rate episodes on stroke and cardiovascular death – an update. Europace 22 June 2023. doi: 10.1093/europace/euad166

(3) Kirchhof P et al. Probing oral anticoagulation in patients with atrial high rate episodes: Rationale and design of the Non–vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes (NOAH – AFNET 6) trial, Am Heart J. 2017;190:12-18. doi: 10.1016/j.ahj.2017.04.015

About the Atrial Fibrillation NETwork (AFNET)

The Atrial Fibrillation NETwork is an interdisciplinary research network comprising scientists and physicians from hospitals and practices dedicated to improving the management of atrial fibrillation through coordinated research in Germany, Europe, and worldwide. Its main objective is to conduct high quality investigator-initiated clinical trials and registries on a national and international level as well as translational reseach projects. The AFNET continues the long-term activities of the network which has been funded by the German Federal Ministry of Research and Education over a decade. Since January 2015, specific projects and infrastructures of the AFNET are funded by the German Centre for Cardiovascular Research (DZHK), and some projects by EU research grants. AFNET has long expertise in the management of atrial fibrillation, but also provides support for work in other fields informing cardiovascular care. The results of 20 years of clinical and translational research improved the lives of patients with cardiovascular diseases and influenced treatment guidelines.
www.af-net.eu

Funding: AFNET, DZHK, Daiichi Sankyo

Registration: NCT 02618577, ISRCTN 17309850

Press Contact

Angelika Leute, PhD

Phone: +49 202 2623395

a.leute@t-online.de

ANET associated events: 

25 August 2023, 8:30, "Stockholm", Stroke and bleeding risk in atrial fibrillation: walking the tight rope (Paulus Kirchhof)

More information.

25 August 2023, 11:15, "Amsterdam", Hot Line Session:  NOAH-AFNET 6: Oral anticoagulation in patients with atrial high rate episodes (Paulus Kirchhof)

More information.

25. August 2023, 16:30, "Hub Rembrandt", Ask the Trialist from Hot Line 1:  NOAH-AFNET 6 (Paulus Kirchhof)

More information.

26 August 2023, 8:30, "Stockholm", Great Debate: controversies in atrial fibrillation - early rhythm control and atrial fibrillation burden (Andreas Götte)

More information.

28 August 2023, 08:30, "Stockholm", Novel approaches: how to provide patient-centred atrial fibrillation care (Stephan Willems)

More information.

28 August 2023, 10:15, "Hub Mondrian", Screening for atrial fibrillation: lessons learned (Renate Schnabel)

More information.

A review article written by the NOAH – AFNET 6 investigators led by Tobias Tönnis from UKE Hamburg summarizes recent evidence on the impact of atrial high rate episodes on stroke and cardiovascular death (1). The new evidence suggests that blood thinners may not be as effective in preventing strokes as previously thought.

Implantable devices and wearables like smart-watches enable continuous or near-continuous monitoring of cardiac rhythm. This leads to detection of short arrhythmias in many people, especially elderly persons with cardiovascular conditions. These arrhythmias, called atrial high rate episodes (AHRE), look like atrial fibrillation (AF). It is well established that blood thinners (anticoagulants) provide effective stroke prevention in patients with AF. Therefore, patients with AHRE are often treated with blood thinners as well.

Dr. Tobias Toennis, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany, explained: “Implanted pacemakers, defibrillators, or cardiac monitors can continuously capture and quantify atrial arrhythmias. Patients with such devices are a suitable population to study the role of infrequent atrial arrhythmias for outcomes in elderly people. AHRE occur in 10-30 % of elderly patients without atrial fibrillation. We reviewed a number of previous AHRE studies and summarized the current knowledge on stroke risk.”

It remains unclear whether anticoagulants can prevent strokes in patients with AHRE. This lack of knowledge is reflected in the current guidelines worldwide. Oral anticoagulants are not routinely recommended in patients with AHRE, but decisions on anticoagulation can be individualized based on clinical risk assessment. 

The reviewed trials indicate: AHRE are associated with an increased thromboembolic risk, even though it is lower than that of clinical AF. The thromboembolic risk appears to be influenced by the duration and frequency of AHRE episodes and by the number and severity of comorbidities. Recently published trials suggest that blood thinners prevent fewer strokes in patients with AHRE than previously thought.

NOAH – AFNET 6 (2), a controlled clinical trial conducted by the German Atrial Fibrillation Network (AFNET), evaluates the efficacy and safety of blood thinners in patients with AHRE. NOAH – AFNET 6 compares treatment with Edoxaban, a non-vitamin K antagonist oral anticoagulant (NOAC), to current therapy (antiplatelet therapy or no antithrombotic therapy) in patients with AHRE aged 65 years or more with at least two stroke risk factors. The trial can be expected to report soon.

The principal investigator of NOAH – AFNET 6, Prof. Kirchhof, UKE, summarized: “NOAH – AFNET 6 will provide much-needed information on the efficacy and safety of oral anticoagulation in patients with AHRE. We hope that these new data will shed some more light on the subject and that further studies will follow.” 

References

(1)    Toennis T et al. The influence of atrial high rate episodes on stroke and cardiovascular death – an update. Europace 22 June 2023. doi: 10.1093/europace/euad166

(2)    Kirchhof et al, Probing oral anticoagulation in patients with atrial high rate episodes: Rationale and design of the Non–vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes (NOAH – AFNET 6) trial, Am Heart J. 2017;190:12-18. doi: 10.1016/j.ahj.2017.04.015

About the Atrial Fibrillation NETwork (AFNET)

The Atrial Fibrillation NETwork is an interdisciplinary research network comprising scientists and physicians from hospitals and practices dedicated to improving the management of atrial fibrillation through coordinated research in Germany, Europe, and worldwide. Its main objective is to conduct high quality investigator-initiated clinical trials and registries on a national and international level. The AFNET continues the long-term activities of the network which has been funded by the German Federal Ministry of Research and Education over a decade. Since January 2015, specific projects and infrastructures of the AFNET are funded by the German Centre for Cardiovascular Research (DZHK).

www.af-net.eu

Press Contact

Angelika Leute, PhD
Phone: +49 202 2623395
a.leute@t-online.de

A sub-study analysis of the EAST – AFNET 4 trial revealed how genetic risk for atrial fibrillation (AF) and stroke interacts with early rhythm control therapy: Early rhythm control reduces cardiovascular events in patients with AF across the spectrum of genetic AF and stroke risks. Today the findings were published in the journal Cardiovascular Research [1].

The EAST – AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention) trial demonstrated that rhythm control therapy – with antiarrhythmic drugs or atrial fibrillation ablation – delivered within one year after AF diagnosis improves outcomes in patients with AF and comorbidities [2]. Early rhythm control (ERC) with antiarrhythmic drugs and/or AF ablation reduced the primary outcome, a composite of cardiovascular death, stroke, and hospitalization for worsening heart failure or acute coronary syndrome, in 2789 patients with early AF and cardiovascular risk factors compared to usual care (UC) over a 5-year follow-up time.

The causes for atrial fibrillation and stroke are manifold and also comprise a heritable component. The genetic risk can be quantified by polygenic risk scores (PRS) using data from large genome-wide association studies. In a collaboration with the Broad Institute of MIT and Harvard in Cambridge, USA, these PRS were tested in the EAST – AFNET 4 study.
Dr. Shinwan Kany, University Medical Center Hamburg Eppendorf, Hamburg, Germany, explained: “Prior studies suggest that patients with a genetic predisposition to AF may suffer more recurrent AF on rhythm control therapy. Additionally, studies using PRS for stroke identified AF patients with an increase in stroke risk when otherwise classified as low risk by CHA2DS2-VASc. This information suggests that early rhythm control therapy could be less effective or less safe in patients with an elevated genomic risk for AF. To assess this, we analyzed the association between genetic AF and stroke risk and cardiovascular events in the EAST – AFNET 4 bio-sample study.”

In the EAST – AFNET 4 bio-sample sub-study, patients were asked to donate a blood sample for later analyses. For the present analysis, blood samples from 1567 of the 2789 trial patients were analyzed. Of these patients, 793 were randomized to early rhythm control, 774 to usual care. They had a median age of 71 years and comprised 44% women. Baseline characteristics were similar between randomized groups.
Consistent with the EAST – AFNET 4 main trial, early rhythm control reduced the primary outcome compared with usual care in the bio-sample sub-population (HR 0.67, p<0.001). The randomized intervention, early rhythm control, did not interact with genetic risk for AF (PRS-AF: interaction p=0.806) or stroke (PRS-Stroke: interaction p=0.765).
As expected, genetic AF risk was associated with recurrent AF, but the attributable risk was modest (HR 1.08), illustrating the effectiveness of modern rhythm control therapy across the spectrum of genetic AF risk. Unexpectedly, genetic stroke risk was associated with a higher risk for heart failure events (HR 1.23, p=0.010) without differences in stroke (HR 1.0, p=0.973) in this well-anticoagulated cohort. The association of genetic stroke risk with heart failure hospitalization was validated in the UK Biobank, a prospective cohort study of over 500,000 participants from the United Kingdom. In the replication analysis, PRS-Stroke was associated with incident AF (HR 1.16, p<0.001) and with incident heart failure (HR 1.08, p<0.001). The association with heart failure was weakened when excluding AF patients (HR 1.03, p=0.001).

EAST – AFNET 4 principal investigator, Professor Paulus Kirchhof, University Medical Center Hamburg Eppendorf, Hamburg, Germany, concluded: “Our bio-sample study shows: Early rhythm control is effective and safe across the spectrum of genetic AF and stroke risks. Our findings support the use of early rhythm control therapy irrespectively of genetic risks for AF and stroke. The association between genetic stroke risk and heart failure calls for research to understand the interactions between polygenic risks, cardiovascular diseases, and treatment.”

Since the publication of the main study result in 2020, different subgroup analyses of the EAST – AFNET 4 study data have been performed. One described the different, variable treatment patterns of antiarrhythmic drugs and AF ablation used in the trial, applied within guideline recommendations [3]. Other subgroup analyses demonstrated the prognostic benefit of early rhythm control in patients with AF and heart failure [4], in patients with asymptomatic AF [5], in patients with different AF patterns [6], in patients with high comorbidity burden [7] and in patients with prior stroke [8]. A mediator analysis identified sinus rhythm as key factor for the effectiveness of early rhythm control [9].

References

[1] Kany S, Al-Taie C, Roselli C, Pirruccello JP, Borof K, Reinbold C, Suling A, Krause L, Reissmann B, Schnabel R, Zeller T, Zapf A, Wegscheider K, Fabritz L, Ellinor PT, Kirchhof P. Association of genetic risk and outcomes in patients with early rhythm control therapy in atrial fibrillation: results from the EAST-AFNET4 study. Cardiovasc Res 2023. DOI: 10.1093/cvr/cvad027

[2] Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, Fetsch T, van Gelder IC, Haase D, Haegeli LM, Hamann F, Heidbüchel H, Hindricks G, Kautzner J, Kuck K-H, Mont L, Ng GA, Rekosz J, Schön N, Schotten U, Suling A, Taggeselle J, Themistoclakis S, Vettorazzi E, Vardas P, Wegscheider K, Willems S, Crijns HJGM, Breithardt G, for the EAST–AFNET 4 trial investigators. Early rhythm control therapy in patients with atrial fibrillation. N Engl J Med 2020; 383:1305-1316. DOI: 10.1056/NEJMoa2019422

[3] Metzner A, Suling A, Brandes A, Breithardt G, Camm AJ, Crijns HJGM, Eckardt L, Elvan A, Goette A, Haegeli LM, Heidbuchel H, Kautzner J, Kuck KH, Mont L, Ng GA, Szumowski L, Themistoclakis S, van Gelder IC, Vardas P, Wegscheider K, Willems S, Kirchhof P. Anticoagulation, therapy of concomitant conditions, and early rhythm control therapy: a detailed analysis of treatment patterns in the EAST - AFNET 4 trial. EP Europace 2022; 24:552–564. DOI: 10.1093/europace/euab200

[4] Rillig A, Magnussen C, Ozga, Suling A, Brandes A, Breithardt G, Camm AJ, Crijns HJGM, Eckardt L, Elvan A, Goette A, Gulizia M, Haegeli LM, Heidbuchel H, Kuck KH, Ng GA, Szumowski L, van Gelder IC, Wegscheider K, Kirchhof P. Early rhythm control therapy in patients with heart failure. Circulation 2021;144(11):845-858. DOI: 10.1161/CIRCULATIONAHA.121.056323

[5] Willems S, Borof K, Brandes A, Breithardt G, Camm AJ, Crijns HJGM, Eckardt L, Gessler N, Goette A, Haegeli LM, Heidbuchel H, Kautzner J, Ng GA, Schnabel R, Suling A, Szumowski L, Themistoclakis S, Vardas P, van Gelder IC, Wegscheider K, Kirchhof P. Systematic, early rhythm control therapy equally improves outcomes in asymptomatic and symptomatic patients with atrial fibrillation: the EAST-AFNET 4 Trial. Eur Heart J. 2022; 43:1219-1230. DOI: 10.1093/eurheartj/ehab593.

[6] Goette a, Borof K, Breithardt G, Camm AJ, Crijns H, Kuck KH, Wegscheider K, Kirchhof P, MD. Presenting Pattern of Atrial Fibrillation and Outcomes of Early Rhythm Control Therapy. J Am Coll Cardiol. 2022; 80:283-95. DOI: 10.1016/j.jacc.2022.04.058

[7] Rillig A, Borof K, Breithardt G, Camm AJ, Crijns HJGM, Goette A, Kuck KH, Metzner A, Vardas P, Vettorazzi E, Wegscheider K, Zapf A, Kirchhof P. Early rhythm control in patients with atrial fibrillation and high comorbidity burden. Circulation. 15 Aug 2022. DOI: 10.1161/CIRCULATIONAHA.122.060274

[8] Jensen M, Suling A, Metzner A, Schnabel R, Borof K, Goette A, Haeusler KG, Zapf A, Wegscheider K, Fabritz L, Diener H-C, Thomalla G, Kirchhof P. Early rhythm-control therapy for atrial fibrillation in patients with a history of stroke: a subgroup analysis of the EAST- AFNET 4 trial. Lancet Neurol 2023; 22: 45–54. DOI: 10.1016/PIIS1474-4422(22)00436-7

[9] Eckardt L, Sehner S, Suling A, Borof K, Breithardt G, Crijns HJGM, Goette A, Wegscheider K, Zapf A, Camm AJ, Metzner A, Kirchhof P. Attaining sinus rhythm mediates improved outcome with early rhythm control therapy of atrial fibrillation: the EAST – AFNET 4 trial. Eur Heart J, 2022. DOI: 10.1093/eurheartj/ehac471

[10] Gottschalk S, Kany S, König H-H, Crijns HJGM, Vardas P, Camm AJ, Wegscheider K, Metzner A, Rillig A, Kirchhof P, Dams J. Cost- effectiveness of early rhythm-control versus usual care in atrial fibrillation care: an analysis based on the German subsample of the EAST-AFNET 4 trial. EP Europace 2023. DOI: 10.1093/europace/euad051

Press Contact
Angelika Leute, PhD
Phone: +49 202 2623395
a.leute@t-online.de

Follow us on Twitter @afnet_ev and hashtag #EASTtrial.

Funding: AFNET, BMBF, DZHK, EHRA, Deutsche Herzstiftung, Abbott, Sanofi

About the EAST – AFNET 4 trial
EAST – AFNET 4 is an investigator-initiated trial (IIT) that compared two different treatment strategies in atrial fibrillation. The EAST – AFNET 4 trial tested whether an early, comprehensive rhythm control therapy can prevent adverse cardiovascular outcomes in patients with atrial fibrillation (AF) compared to usual care.
A total of 2789 patients with early AF (diagnosed less than a year ago) and at least two cardiovascular conditions (approximating a CHA₂DS₂-VASc score >=2) were enrolled by 135 sites in 11 countries during 2011 to 2016. Patients were randomized 1:1 to early rhythm control therapy or usual care, stratified by sites. Patients in both groups received guideline-recommended treatment for underlying cardiovascular conditions, anticoagulation, and rate control.

All patients in the early rhythm control group received antiarrhythmic drugs or catheter ablation after randomization (chosen by the local study teams). Rhythm control therapy was escalated with AF ablation and/or antiarrhythmic drugs when recurrent AF was documented clinically or by ECG, including monitoring with patient-operated ECG devices.

Patients in the usual care group were initially managed with rate control. Rhythm control therapy was only used to improve atrial fibrillation-related symptoms despite optimal rate control, following current guidelines.

About the Atrial Fibrillation NETwork (AFNET)
The Atrial Fibrillation NETwork is an interdisciplinary research network comprising scientists and physicians from hospitals and practices dedicated to improving the management of atrial fibrillation through coordinated research in Germany, Europe, and worldwide. Its main objective is to conduct high quality investigator-initiated clinical trials and registries on a national and international level. The AFNET continues the long-term activities of the network which has been funded by the German Federal Ministry of Research and Education over a decade. Since January 2015, specific projects and infrastructures of the AFNET are funded by the German Centre for Cardiovascular Research (DZHK).

www.af-net.eu