Ablation outperforms drug therapy as an initial treatment for atrial fibrillation

Drug therapy is typically recommended for the initial treatment of patients with atrial fibrillation (AFib), but should physicians consider starting off with catheter ablation instead?

A new analysis in the New England Journal of Medicine explored that very question.

“Catheter ablation is superior to antiarrhythmic drugs in maintaining sinus rhythm and improving quality of life in patients in whom drugs have already failed,” wrote lead author Jason G. Andrade, MD, of Vancouver General Hospital, and colleagues. “However, catheter ablation as first-line treatment may be better than antiarrhythmic drugs in preventing the recurrence of atrial tachyarrhythmia, reducing the AFib burden, and improving patient well-being.”

Andrade et al. evaluated more than 300 patients with symptomatic, untreated AFib who were randomly chosen to either undergo catheter ablation with a cryothermy balloon or drug therapy. Cardiac monitoring devises were used to detect atrial tachyarrhythmia.

All patients were treated from Jan. 17, 2017, to Dec. 21, 2018. Each patient was called after seven days, and a follow-up visit was scheduled after three, six and 12 months.

Overall, the team reported, the recurrence of any atrial tachyarrhythmia—AFib, atrial flutter or atrial tachycardia—that lasted at least 30 seconds was reported in 42.9% of ablation patients and 67.8% of drug therapy patients. Symptomatic atrial tachyarrhythmia was observed in 11% of ablation patients and 26.2% of drug therapy patients.

Serious adverse events, meanwhile, remained low in both groups, occurring in 3.2% of ablation patients and 4% of drug therapy patients. There were no procedural deaths or thromboembolic complications in either group.

The authors highlighted the importance of these findings, describing AFib as a “progressive disease.”

“Early in its course, AFib is triggered by one or more ectopic foci that most commonly arise from the pulmonary veins,” they wrote. “Intervention early in the natural history of AFib may limit disease progression by interrupting progressive pathophysiological changes and may improve clinical outcomes.”

Discussing the comparable safety of the two options, Andrade and colleagues also noted that an invasive procedure such as ablation “is associated with more up-front risk than medical therapy.”

The study is available here.