ETOH-AF

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https://www.nejm.org/doi/full/10.1056/NEJMoa1817591

ETOH-AF

Clinical Question

In patients with regular alcohol consumption and prior symptomatic atrial fibrillation, does abstinence from alcohol reduce risk of recurrent atrial fibrillation?

Bottom Line

For patients with regular alcohol consumption and prior symptomatic atrial fibrillation, abstinence from alcohol compared to baseline alcohol consumption decreased the primary endpoints of recurrent atrial fibrillation and atrial fibrillation burden.

Major Points

Alcohol consumption has been identified as a risk factor for atrial fibrillation, but the benefit of abstinence on rate of recurrent atrial fibrillation remains unclear.

Guidelines

No guidelines reflect the results of this trial as of January 2020.

Design

  • Randomized, open-label, prospective, multicenter trial
  • N=146
    • Abstinence from alcohol consumption (n=70)
    • Baseline alcohol consumption (n=70)
  • Setting: 6 centers in Australia
  • Enrollment: March 2016 to February 2018
  • Follow-up: Median 6 months (interquartile range, 6 months to 6 months)
  • Analysis: Intention-to-treat
  • Primary end points:
    • Recurrent atrial fibrillation >30 seconds in duration
    • Median percentage of time in atrial fibrillation

Population

Inclusion Criteria

  • 18-85 years old
  • Symptomatic paroxysmal atrial fibrillation with greater than or equal to 2 episodes in the prior 6 months or symptomatic persistent atrial fibrillation on a rhythm-control strategy
  • Regular alcohol consumption of 10 or more standard drinks (120 g of alcohol) per week

Exclusion Criteria

  • Alcohol dependence or abuse
  • Left ventricular ejection fraction less than 35%
  • Clinically significant non-cardiac disease
  • Concomitant psychiatric disorder

Baseline Characteristics

From the alcohol abstinence group.

  • Mean age: 61.69.4 years
  • Male sex: 87%
  • Weight: 89.716.0 kg
  • BMI: 28.44.4
  • Hypertension: 44%
  • Diabetes mellitus: 7%
  • Dyslipidemia: 16%
  • Previous TIA or stroke: 10%
  • Previous or current smoker: 19%
  • OSA: 17%
  • Previous heart failure: 9%
  • CHA2DS2-VASc: 1.51.2
  • Paroxysmal atrial fibrillation: 64%
  • Persistent atrial fibrillation: 36%
  • Previous atrial fibrillation ablation: 29%
  • Pacemaker or loop recorder: 36%
  • Antiarrhythmic therapy: 63%
    • Amiodarone: 9%
    • Sotalol: 29%
    • Flecainide: 26%
  • Alcohol intake: 16.87.7 standard drinks/week
  • Beverages consumed
    • Wine: 69%
    • Beer: 49%
    • Spirits: 19%
  • Binge drinking: 29%

Interventions

  • Randomized to abstinence from alcohol use or continued baseline alcohol use

Outcomes

Comparisons are abstinence from alcohol use vs. continued baseline alcohol use.

Primary Outcome

Recurrent atrial fibrillation >30 seconds in duration
53% vs. 73% (HR 0.55; 95% CI 0.36 to 0.84; p=0.005)
Median percentage of time in atrial fibrillation
0.5% (IQR 0..0 to 3.0) vs. 1.2% (IQR 0.0 to 10.3) (p=0.01)

Secondary Outcomes

Subgroup Analysis

Adverse Events

No adverse events other than the outcomes listed above were reported.

Criticisms

It is unclear if the results would apply to patients with higher burdens of atrial fibrillation.

Funding

Further Reading

https://www.nejm.org/doi/full/10.1056/NEJMoa1817591 https://www.nejm.org/doi/full/10.1056/NEJMe1914981