Rhythm control for management of patients with atrial fibrillation: balancing the use of antiarrhythmic drugs and catheter ablation

Catheter ablation of persistent atrial fibrillation

Catheter ablation of atrial fibrillation (AF) is performed increasingly worldwide and with the development of new technologies the procedures have become safer and more effective after a single attempt, particularly with paroxysmal AF. However, success rates for persistent AF ablation remain far lower than paroxysmal AF and there is large variation in the strategies used worldwide. This review describes the background to persistent AF ablation, the different strategies used and their associated risks and benefits, developing technologies and the authors' perspective on the future of this rapidly evolving area.

Radiofrequency catheter ablation for atrial fibrillation

Antiarrhythmic drugs are the first-line treatment for atrial fibrillation (AF); as a result, catheter ablation usually is not considered until a patient is experiencing symptomatic AF refractory to at least one antiarrhythmic medication or is intolerant to medical therapy. For these patients, catheter ablation is shown to be more effective than medical therapy for controlling AF. This article reviews catheter ablation and its indications.

What can rhythm control therapy contribute to prognosis in atrial fibrillation?

Atrial fibrillation (AF) is a global healthcare problem of growing prevalence and major significance. The consequences of AF include an increased rate of death, stroke and heart failure. Theoretically, a therapeutic strategy aiming at restoration and maintenance of sinus rhythm should offset the prognosis impairment associated with AF. However, these expectations were disproven in large randomised controlled trials comparing conventional antiarrhythmic drugs for rhythm control with conventional rate control. These apparently contradictory findings suggest that rhythm control strategies require better therapeutic instruments. These improvements may involve drugs and/or interventions with optimised risk-benefit profile and which also appreciate the specific atrial pathology and the patient's comorbidities. This article addresses important aspects of rhythm control strategies, which may have the potential of a beneficial contribution to the prognosis of AF patients.

Effect of Radiofrequency Catheter Ablation for Atrial Fibrillation on Morbidity and Mortality

Background—

This study examined the effect of radiofrequency catheter ablation (RFA) on reducing morbidity and mortality among patients with atrial fibrillation (AF).

Methods and Results—

A retrospective cohort of patients with AF without prior stroke or heart failure (HF) who underwent RFA between 2003 and 2009 was identified using Taiwan’s National Health Insurance claims database. Outpatients with AF who met the same enrollment criteria but did not receive RFA were matched (≤1:20) by hospitals and dates to serve as controls. Outcomes of interest were death, stroke, or hospitalization for HF. A proportional hazard Cox regression model adjusted by propensity scores (based on age, sex, hypertension, diabetes mellitus, comorbidities, medications, and medical resource utilization) was applied to estimate the hazard ratio and 95% confidence interval. A total of 846 patients with AF who received RFA and 11 324 matched AF controls were included, with a mean follow-up of 3.74 and 3.96 years, respectively. RFA was associated with a lower hazard for stroke (hazard ratio, 0.57; 95% confidence interval, 0.35–0.94; P =0.026). The reduction in the hazard for death and HF did not reach statistical significance (hazard ratio, 0.88; 95% confidence interval, 0.62–1.23; P =0.451 and hazard ratio, 0.78; 95% confidence interval, 0.55–1.12; P =0.185, respectively). Additional analysis using death as a competing risk showed similar results for stroke and HF.

Conclusions—

RFA did not reduce mortality or hospitalization for HF during the immediate 3.5-year follow-up. Although a beneficial effect on stroke prevention associated with RFA was suggested, residual confounding attributable to unmeasured factors remains a concern.