Recent-Onset Atrial Fibrillation: Emma Svennberg, MD, PhD, Explains New Evidence, Risks, and Opportunities for Early Rhythm Control

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EP LAB DIGEST. 2025;26(1):Online Only.

Interview by Jodie Elrod

Early detection of atrial fibrillation (AF) is rapidly reshaping the way electrophysiologists diagnose and treat the most common sustained arrhythmia. With consumer wearables, device-based monitoring, and artificial intelligence (AI)-driven electrocardiogram (ECG) prediction accelerating the identification of patients in the earliest stages of AF, clinicians are facing new questions—and new opportunities. In this exclusive interview with EP Lab Digest, Emma Svennberg, MD, PhD, lead author of the recent European Heart Journal review¹ on recent-onset AF, discusses the evolving evidence behind early rhythm control, the growing importance of AF burden, and how risk factor modification and smarter screening pathways may shift the trajectory of the disease. Her insights provide a forward-looking roadmap for EP labs navigating the complexities of this expanding patient population.

EAST-AFNET 4 and subsequent analyses have reignited interest in intervening early. Given the key point that early rhythm control of recent-onset AF may be more effective than delayed treatment, how aggressive should experienced centers be in offering ablation or antiarrhythmic therapy during the first year after diagnosis—and how should we balance this against the potential overtreatment of low-burden cases?

EAST-AFNET 4 demonstrated that intervening early (within the first year after AF presentation) reduces cardiovascular events, and our review reinforces that maintaining sinus rhythm is most achievable early in the disease process. However, this needs to be balanced against the risk of overtreating individuals with very low AF burden or minimal symptoms.

I think the best way forward is a selective, risk-directed strategy. We should be more proactive with invasive strategies in patients who show early signs of progression, evidence of atrial cardiomyopathy, coexisting heart failure, or a high symptom burden. 

Conversely, for patients with truly minimal AF burden and low risk of progression, a less interventional approach remains appropriate.

Importantly, many of these patients also present with modifiable cardiometabolic comorbidities, such as hypertension, obesity, diabetes, or sleep apnea, which may be reversible and can profoundly influence AF trajectory. Addressing these conditions early may not only improve overall cardiovascular outcomes, but also enhance the effectiveness of rhythm control therapy and potentially lessen the need for invasive strategies.

In practice, this means integrating AF burden, comorbidity profiles, atrial structure and function, and patient preference to identify who stands to benefit most from early intervention.

Consumer wearables and devices have expanded detection to the “pre-clinical” phase of AF, and AI-based ECG prediction models have shown accuracy in predicting AF before its clinical presentation. From an EP standpoint, how should labs operationalize these tools to triage device-detected or AI-predicted AF for rhythm control or anticoagulation decisions?

The expansion of AI-based ECG prediction and wearable monitoring presents an important opportunity to detect AF earlier and intervene before significant progression occurs. For patients flagged by AI-ECG prediction models, the next logical step is targeted rhythm monitoring, ideally using a wearable ECG device capable of confirming, or refuting, the diagnosis.

To avoid a flood of unsolicited tracings and unstructured alerts, wearable data should be integrated into existing remote monitoring pathways wherever possible, or alternatively, patients should be instructed to bring stored recordings to scheduled visits. A structured workflow is essential to prevent unnecessary clinical burden and ensure that meaningful episodes receive timely evaluation.

Looking ahead, AI models predicting post-ablation recurrence may become particularly valuable. These tools could help personalize follow-up intensity, stratify patients who need closer rhythm surveillance, and optimize resource use in EP programs.

This work connects risk factor modification—for obesity, hypertension, sleep apnea, and diabetes—to prevention of AF progression. How can EP programs better embed structured lifestyle and metabolic interventions alongside ablation pathways, and should electrophysiologists directly own that component of care?

Lifestyle and cardiometabolic comorbidities including obesity, hypertension, sleep apnea, and diabetes are major drivers of AF onset and progression, and our review highlights that addressing these factors early can meaningfully modify the disease course. However, this does not mean that electrophysiologists must deliver these interventions themselves. What EP programs do need is an organized, reliable structure for referral and follow-up. 

Early AF diagnosis provides a valuable opportunity to engage patients in lifestyle management, particularly while cardiometabolic conditions may still be reversible.

EP clinics can play a central role by identifying comorbidities early through the use of structured screening tools, as demonstrated in the ongoing EHRA-PATHS study.² Once identified, EP clinics can refer patients into established lifestyle and metabolic programs. Importantly, structured, accessible, and standardized pathways ensure that every patient can receive comprehensive care without requiring the EP to personally deliver each component.

The article notes a growing interest in targeting the prevention of AF progression as a novel therapeutic endpoint. For future studies, what endpoints—AF burden reduction, sinus rhythm maintenance, or prevention of HF hospitalization—do you believe would best demonstrate the value of early, integrated management of recent-onset AF? 

From the perspective of the arrhythmia itself, I believe AF burden is the key metric. For future trials in recent-onset AF, I would much prefer endpoints that focus on change in AF burden and prevention of progression rather than relying on a simple “30-second” AF criterion—particularly post-ablation—as it is a very blunt, binary tool that fails to reflect the lived reality of patients or the underlying biology of AF. Continuous or near-continuous monitoring (eg, cardiac implantable electronic devices, implantable loop recorders, and wearables) allows us to quantify how much time a patient actually spends in AF and to evaluate whether early, integrated management can keep that burden low and prevent progression from paroxysmal to persistent AF, which carries important prognostic implications. 

Beyond arrhythmia metrics, the clinical outcomes most relevant for demonstrating the value of early care would be heart failure (HF)-related outcomes, particularly HF hospitalizations and the development or worsening of left ventricular dysfunction, given the strong bidirectional relationship between AF and HF. Certainly, stroke and systemic embolism remain important outcomes, but with declining event rates, they have become more challenging endpoints to study. Looking ahead, factor XIa (FXIa) inhibitors may play a unique role in this population. If ongoing trials confirm that FXIa inhibition maintains stroke protection with significantly lower bleeding risk, these agents could be particularly attractive for patients with low AF burden, recent-onset AF, or device-detected AF, where the net clinical benefit of current anticoagulation is often finely balanced. For such patients, who may spend years moving in and out of low-burden AF, an anticoagulant with a markedly improved bleeding profile would be a major step forward and could enable safer evaluation of early rhythm control strategies. 

In addition to clinical outcomes, we should, of course, also remember to include quality-of-life (QoL) data—especially for younger, recent-onset AF patients who may have low CHA₂DS₂-VA scores yet experience substantial symptom burden and lifestyle impact.

Ideally, future studies in recent-onset AF will combine AF-specific metrics (burden, progression) with patient-centered clinical endpoints (HF, stroke, QoL) to capture the full benefit (or lack thereof) of early, integrated management rather than focusing solely on whether AF appears for 30 seconds on a monitor or not.

The transcripts have been edited for clarity and length.

References

1.     Svennberg E, Freedman B, Andrade JG, et al. Recent-onset atrial fibrillation: challenges and opportunities. Eur Heart J. 2025 Aug 28:ehaf478. doi:10.1093/eurheartj/ehaf478

2.     EHRA-PATHS: Addressing multimorbidity in elderly atrial fibrillation patients through interdisciplinary, patient-centered, systematic care pathways. EHRA-PATHS. Accessed December 17, 2025. https://ehra-paths.eu/