Antiarrhythmic drugs after ablation for atrial fibrillation: the hope, the hype, and the reality

Three-year incidence of pacemaker implantation in patients with atrial fibrillation and sinus node dysfunction receiving ablation versus antiarrhythmic drugs

BACKGROUND

Sinus node dysfunction (SND) is commonly seen in patients with atrial fibrillation (AF). The purpose of this study was to compare the incidence of pacemaker implantation among patients with SND and AF treated with catheter ablation (CA) versus anti-arrhythmic drugs (AADs).

METHODS

The 2013-2022 Optum Clinformatics database, an administrative claims database for commercially insured individuals in the United States (US), was used for this study. Patients with AF and SND and a history of at least one AAD prescription were identified and classified into CA or AAD cohorts based on subsequent treatment received. Inverse probability treatment weighting was applied to balance socio-demographic and clinical characteristics between the cohorts. Weighted Cox regression modeling was used to evaluate the differential risk of incident permanent pacemaker (PPM) implantation. Sub-analyses were performed by AF type (paroxysmal versus persistent).

RESULTS

A total of 1206 patients in the AAD cohort and 1624 patients in the CA cohort were included. Study cohorts were well-balanced post-weighting. The incidence rate of PPM implantation (per 1000 person-year) was 55.8 for the CA cohort and 117.8 for the AAD cohort. Regression analysis demonstrated that the CA cohort had 42% lower risk of incident PPM implantation than those treated with AADs (hazard ratio [HR], 0.58; 95% CI, 0.46-0.72, p < 0.001). CA-treated patients had lower risks of PPM implantation versus AAD-treated patients among those with paroxysmal AF (HR, 0.48; 95% CI, 0.34-0.69, p < 0.001) and persistent AF (HR, 0.57; 95% CI, 0.40-0.81, p = 0.002).

CONCLUSIONS

Patients with AF and SND treated with CA have significantly lower risks of incident PPM implantation compared with those treated with an AAD.

Heart failure risk in patients with atrial fibrillation treated with catheter ablation vs antiarrhythmic drugs

Background

Atrial fibrillation (AF) increases heart failure (HF) risk. Whereas the risk of HF-related hospitalization and mortality are known in the setting of AF, the impact of AF treatment on HF development is understudied.

Objective

The purpose of this study was to compare HF incidence among AF patients treated with antiarrhythmic drugs (AADs) vs catheter ablation (CA).

Methods

AF patients with 1 prior AAD usage were identified in 2014-2022 Optum Clinformatics database. Patients were classified into 2 cohorts: those receiving CA vs those receiving a different AAD prescription. The 2 cohorts were matched on sociodemographic and clinical covariates using propensity score matching technique. Cox regression model was used to compare incident HF risk in the 2 cohorts. Subgroup analyses were performed by race/ethnicity, sex, AF subtype, and CHA2DS2-VASc score.

Results

After matching, 9246 patients were identified in each cohort (AAD and CA). Patients receiving CA had a 57% lower risk of incident HF than those treated with AADs (hazard ratio [HR] 0.43; 95% confidence interval [CI] 0.40-0.46). Subgroup analysis by race/ethnicity depicted similar results, with non-Hispanic White (HR 0.43; 95% CI 0.40-0.46), non-Hispanic Black (HR 0.46; 95% CI 0.35-0.60), Hispanic (HR 0.53; 95% CI 0.40-0.70), and Asian (HR 0.46; 95% CI 0.24-0.92) patients treated with CA (vs AAD) having significantly lower risk of HF, respectively. The effect size of CA remained significant in subgroups defined by sex, AF subtypes, and CHA2DS2-VASc score.

Conclusion

AF patients receiving CA had ∼57% lower risk of developing HF than those receiving AAD. The lower risk of HF associated with CA vs AAD persisted across different race/ethnicity, sex, AF subtypes, and CHA2DS2-VASc score.

Atrial Fibrillation and Ventricular Tachyarrhythmias: Advancements for Better Outcomes

Cardiac arrhythmias are associated with several cardiac diseases and are prevalent in people with or without structural and valvular abnormalities. Ventricular arrhythmias (VA) can be life threating and their onset require immediate medical attention. Similarly, atrial fibrillation and flutter lead to stroke, heart failure and even death. Optimal treatment of VA is variable and depends on the medical condition associated with the rhythm disorder (which includes reversible causes such as myocardial ischemia or pro-arrhythmic drugs). While an implanted cardioverter defibrillator is often indicated in secondary prevention of VA. This review highlights the newest advancements in these techniques and management of ventricular and atrial tachyarrhythmias, along with pharmacological therapy.