Long-Term Cost-Effectiveness Comparison of Catheter Ablation and Antiarrhythmic Drugs in Atrial Fibrillation Treatment Using Discrete Event Simulation

Antiarrhythmic drug therapy and catheter ablation in patients with paroxysmal or persistent atrial fibrillation: a systematic review and meta-analysis

BACKGROUND

Catheter ablation and antiarrhythmic drug therapy are utilized for rhythm control in atrial fibrillation (AF), but their comparative effectiveness, especially with contemporary treatment modalities, remains undefined. We conducted a systematic review and meta-analysis contrasting current ablation techniques against antiarrhythmic medications for AF.

METHODS

We searched PubMed, SCOPUS, Cochrane CENTRAL, and Web of Science until November 2023 for randomized trials comparing AF catheter ablation with antiarrhythmics, against antiarrhythmic drug therapy alone, reporting outcomes for > 6 months. Four investigators extracted data and appraised risk of bias (ROB) with ROB 2 tool. Meta-analyses estimated pooled efficacy and safety outcomes using R software.

RESULTS

Twelve trials (n = 3977) met the inclusion criteria. Catheter ablation was associated with lower AF recurrence (relative risk (RR) = 0.44, 95%CI (0.33, 0.59), P ˂ 0.0001) and hospitalizations (RR = 0.44, 95%CI (0.23, 0.82), P = 0.009) than antiarrhythmic medications. Catheter ablation also improved the physical quality of life component score (assessed by a 36-item Short Form survey) by 7.61 points (95%CI -0.70-15.92, P = 0.07); but, due to high heterogeneity, it was not statistically significant. Ablation was significantly associated with higher procedural-related complications [RR = 15.70, 95%CI (4.53, 54.38), P < 0.0001] and cardiac tamponade [RR = 9.22, 95%CI (2.16, 39.40), P = 0.0027]. All-cause mortality was similar between the two groups.

CONCLUSIONS

For symptomatic AF, upfront catheter ablation reduces arrhythmia and hospitalizations better than continued medical therapy alone, albeit with moderately more adverse events. Careful patient selection and risk-benefit assessment are warranted regarding the timing of ablation.

Economic evaluation of first-line cryoballoon ablation versus antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from an English National Health Service perspective

INTRODUCTION

Three recent randomised controlled trials have demonstrated that pulmonary vein isolation as an initial rhythm control strategy with cryoablation reduces atrial arrhythmia recurrence in patients with symptomatic paroxysmal atrial fibrillation (PAF) compared with antiarrhythmic drug (AAD) therapy. The aim of this study was to evaluate the cost-effectiveness of first-line cryoablation compared with first-line AADs for treating symptomatic PAF in an English National Health Service (NHS) setting.

METHODS

Individual patient-level data from 703 participants with PAF enrolled into Cryo-FIRST (Catheter Cryoablation Versus Antiarrhythmic Drug as First-Line Therapy of Paroxysmal Atrial Fibrillation), STOP AF First (Cryoballoon Catheter Ablation in an Antiarrhythmic Drug Naive Paroxysmal Atrial Fibrillation) and EARLY-AF (Early Aggressive Invasive Intervention for Atrial Fibrillation) were used to derive the parameters applied in the cost-effectiveness model (CEM). The CEM comprised a hybrid decision tree and Markov structure. The decision tree had a 1-year time horizon and was used to inform the initial health state allocation in the first cycle of the Markov model (40-year time horizon; 3-month cycle length). Health benefits were expressed in quality-adjusted life years (QALYs). Costs and benefits were discounted at 3.5% per year. Model outcomes were generated using probabilistic sensitivity analysis.

RESULTS

The results estimated that cryoablation would yield more QALYs (+0.17) and higher costs (+£641) per patient over a lifetime than AADs. This produced an incremental cost-effectiveness ratio of £3783 per QALY gained. Independent of initial treatment, individuals were expected to receive ~1.2 ablations over a lifetime. There was a 45% relative reduction in time spent in AF health states for those initially treated with cryoablation.

DISCUSSION

AF rhythm control with first-line cryoablation is cost effective compared with first-line AADs in an English NHS setting.

Cost Effectiveness of Strategies to Manage Atrial Fibrillation in Middle- and High-Income Countries: A Systematic Review

BACKGROUND

Atrial fibrillation (AF) remains the most common form of cardiac arrhythmia. Management of AF aims to reduce the risk of stroke, heart failure and premature mortality via rate or rhythm control. This study aimed to review the literature on the cost effectiveness of treatment strategies to manage AF among adults living in low-, middle- and high-income countries.

METHODS

We searched MEDLINE (OvidSp), Embase, Web of Science, Cochrane Library, EconLit and Google Scholar for relevant studies between September 2022 and November 2022. The search strategy involved medical subject headings or related text words. Data management and selection was performed using EndNote library. The titles and abstracts were screened followed by eligibility assessment of full texts. Selection, assessment of the risk of bias within the studies, and data extraction were conducted by two independent reviewers. The cost-effectiveness results were synthesised narratively. The analysis was performed using Microsoft Excel 365. The incremental cost effectiveness ratio for each study was adjusted to 2021 USD values.

RESULTS

Fifty studies were included in the analysis after selection and risk of bias assessment. In high-income countries, apixaban was predominantly cost effective for stroke prevention in patients at low and moderate risk of stroke, while left atrial appendage closure (LAAC) was cost effective in patients at high risk of stroke. Propranolol was the cost-effective choice for rate control, while catheter ablation and the convergent procedure were cost-effective strategies in patients with paroxysmal and persistent AF, respectively. Among the anti-arrhythmic drugs, sotalol was the cost-effective strategy for rhythm control. In middle-income countries, apixaban was the cost-effective choice for stroke prevention in patients at low and moderate risk of stroke while high-dose edoxaban was cost effective in patients at high risk of stroke. Radiofrequency catheter ablation was the cost-effective option in rhythm control. No data were available for low-income countries.

CONCLUSION

This systematic review has shown that there are several cost-effective strategies to manage AF in different resource settings. However, the decision to use any strategy should be guided by objective clinical and economic evidence supported by sound clinical judgement.

REGISTRATION

CRD42022360590.

Catheter ablation using advanced porous tip contact force–sensing radiofrequency catheter: Impact on health care utilization among patients with persistent atrial fibrillation

Background

Catheter ablation (CA) is an effective treatment for patients with persistent atrial fibrillation (PsAF); however, little is known about its impact on health care utilization for patients with PsAF. The ThermoCool SmartTouch SF (STSF) catheter (Biosense Webster) incorporates an advanced porous tip and contact force–sensing technology.

Objective

The purpose of this study was to determine health care utilization among patients with PsAF who underwent ablation with the STSF catheter.

Methods

A retrospective cohort study using the Premier Healthcare Database identified patients with PsAF undergoing CA with the STSF catheter in inpatient and outpatient settings. The proportion of patients experiencing AF-related inpatient admissions, outpatient admissions, emergency department (ED) visits, electrical cardioversion, and a composite outcome in the 12 months pre- vs postablation were compared using the McNemar test. Subanalyses were performed on study outcomes by race/ethnicity.

Results

The final sample included 3077 patients (mean age 65.9 years; 31.7% female). Among patients with PsAF undergoing ablation with the STSF catheter, relative reductions in health care utilization in the 12 months post- vs preablation included 55.3% in AF-related inpatient admissions (P <.0001), 38.9% in outpatient admissions (P <.0001), 52.4% in ED visits (P <.0001), and 61.2% in electrical cardioversions (P <.0001). Composite outcome utilization in the 12 months post- vs preablation declined by 40.2% (P <.0001) for the overall cohort, 40.0% for White patients (P <.0001), 52.2% for Black patients (P <.0001), and 50.1% for Asian patients (P = .032).

Conclusion

Significant improvements in health care utilization were observed among PsAF patients who underwent ablation using the STSF catheter. Improvements were particularly marked in underrepresented racial and ethnic groups.