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Medically reviewed by Dr. Shani S. Saks, D.O. on August 2, 2023

The health benefits of early rhythm control are associated with reasonable costs, as represented by incremental cost-effectiveness ratios.

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia observed in the adult population, with a one-third lifetime risk among individuals of European descent. By 2060, it is anticipated that approximately 18 million European Union citizens will be affected by AF. 

Patients with this condition are at increased risk for myocardial infarctions, heart failure events, and death. AF also substantially contributes to the incidence of strokes. As a result, the rising prevalence of atrial fibrillation is associated with a growing socioeconomic burden on healthcare systems and society as a whole. 

A randomized controlled trial demonstrated that early rhythm control (ERC) decreased the composite primary outcome rate by 20%, which included cardiovascular death, worsening heart failure, acute coronary syndrome, and stroke. This study evaluated the cost-effectiveness of ERC versus usual care in atrial fibrillation (AF). The findings were published in the journal Europace.

Study Characteristics

A total of 1664 German participants were equally randomized to usual care and ERC groups. The mean age of the ERC and usual care group participants was 70.16 years and 70.87 years, respectively. The time to first occurrence of a primary outcome event (cardiovascular death, stroke, or hospitalization for worsening heart failure or acute coronary syndrome) and number of deaths were relatively lower in the ERC group than in the usual care group.

Cost-Effectiveness of Early Control Rhythm

Compared to usual care, ERC was significantly and non-significantly associated with higher mean medication costs and higher mean hospitalization costs, respectively, in the unadjusted analysis. In the adjusted analysis, compared to the usual care group, the ERC group was non-significantly associated with higher mean total costs and longer mean survival time, whereas it was significantly associated with a longer mean time to primary outcome event occurrence. ERC’s probability of being cost-effective was elevated with higher values of willingness to pay.

Cost-Effectiveness of ERC Demonstrates Variability at ≥ €55,000 per Year

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The health benefits of ERC are associated with reasonable costs, as represented by incremental cost-effectiveness ratios, and ERC’s cost-effectiveness is highly variable when the willingness-to-pay value is ≥ € 55,000 per year without a primary outcome or additional life year.

Additional Research on Cost-Effectiveness of ERC Needed

Incorporating a more comprehensive cost analysis approach, assessing the cost-effectiveness of ERC in various healthcare systems or within subgroups exhibiting the greatest clinical efficacy of ERC, and exploring the cost-effectiveness of alternative modalities of ERC should be the subject of additional research.


Gottschalk, S., Kany, S., König, H., Crijns, H. J., Vardas, P., Camm, A. J., Wegscheider, K., Metzner, A., Rillig, A., Kirchhof, P., & Dams, J. (2023). Cost-effectiveness of early rhythm control vs. usual care in atrial fibrillation care: an analysis based on data from the EAST-AFNET 4 trial. Europace, 25(5). https://doi.org/10.1093/europace/euad051