Conflict of Interest When to Consider Antiarrhythmic Drugs vs - - PDF document

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When to Consider Antiarrhythmic Drugs vs Catheter Ablation

Eric N Prystowsky, MD Director, Cardiac Arrhythmia Service, St Vincent Hospital, Indianapolis, IN Consulting Professor of Medicine, Duke Univ Medical Center

Conflict of Interest

• Consultant: Medtronic; Abbott EP;

Stereotaxis; CardioNet

• Board of Directors: Stereotaxis
• Stock: Stereotaxis
• Institutional Fellowship support: Boston

Scientific; Medtronic; St Jude

When to Consider Sinus Rhythm vs Rate Control

Screened N = 7401 Withdrew n = 71 Enrolled N = 4060

Status Unknown n = 26

Follow-up N = 3963

Declined n = 3341(45%)

AFFIRM Investigators NEJM 2002; 347:1825-33

AFFIRM

Enrollment

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Rate Versus Rhythm Control in Patients with

• A. Fib (AFFIRM)

From: AFFIRM investigators NEJM 2002; 347:1825

“Documented” Safety of Persistent Atrial Fibrillation

AGE 62 72 100 Effect on Rhythm vs. Rate Control Therapy

• n Mortality Over Time

From: Ionescu-Ittu R et al. Arch Intern Med 2012; 172: 997

Long-term Outcomes in Patients With AF; AF/RFA; No AF History

From: Bunch TJ et al. J Cardiovasc Electrophysiol 2011; 22: 839

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Cognitive Function Evaluation in Controls (green), Paroxysmal AF (blue) and Persistent AF (red)

From: Gaita et al., JACC 2013; 21: 1990-7

If there was a safe and effective method to restore and maintain sinus rhythm, would you allow your patient to remeain in atrial fibrillation?

Patient N-56

HPI: 47-year-old man presents for a second opinion regarding recently diagnosed A. Fib. (CHADS-VASc = 0). He was at routine yearly PCP visit and asymptomatic and A. Fib was diagnosed with HR > 120/min. His last exam was a year ago and without A. Fib. Apixaban was started and DC cardioversion done with IRAF one month later. Initial ECHO with LVEF 40%; LA 4.5 cm; repeat LVEF 50% at cardioversion (carvedilol 6.25 mg bid). PMH: Non-contributory FH: No arrhythmias

Sinus rhythm: A bridge to the Future

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Freedom from Chronic Treatment Failure (STOP AF)

From: Packer DL et al. J Am Coll Cardiol 2013; 61: 1713-23

Goal of Antiarrhythmic Therapy to Maintain Sinus Rhythm

• Minimize frequency and duration of

AF episodes to allow a better quality

• f life
• Neither ablation nor antiarrhythmic

drug therapy decides whether a patient receives anticoagulation

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Results from Randomized Trials of Catheter Ablation vs. Antiarrhythmic Drug Therapy in Atrial Fibrillation

From: Prystowsky EN JAMA 2015, 314: 278-288 From: 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation, Circulation, March 28, 2014

Strategies for Rhythm Control in Patients with Paroxysmal and Persistent AF

Inhospital Complications Associated with Ablation of A. Fib in USA, 2000-2010 (n=93,801)

From: Deshmukh, Circulation 9/23/13 (online)

• Nationwide Inpatient Sample (NIS)
• Complications: 5,909 (6.29%)
• Annual Operator Volume (n=49, 4443)

< 25 81% 25-50 10% > 50 9%

• Annual Hospital Volume

< 50 68% 50-100 17% > 100 14%

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Percent Complication Rate by Annual Operator Volume

From: Deshmukh, Circulation 9/23/13 (online)

Catheter ablation as first line therapy for patients with A Fib

• Patient preference after full discussion of

risks and benefits

• BTS with need for PM with AA drugs
• Amiodarone only AA durg choice
• Younger patient facing decades of therapy

Proposed Treatment Algorithm for Paroxysmal and Persistent Atrial Fibrillation

From: Prystowsky EN JAMA 2015, 314: 278-288

Back up slides

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Radiofrequency Ablation vs. Antiarrhythmic Drugs as First-line Therapy for Paroxysmal AF (RAAFT-2)

• 127 patients randomized from 7/06 to 1/10 from

16 centers

• Drugs:

flecainide (69%) 175.8 mg/day; propafenone (25%) 487.7 mg/day

• Ablation:

PVI; CFAE (17%); roof line (21%); CTI (19%)

• Primary outcome: time to first recurrence of any atrial

tachyarrhythmia > 30 sec duration

From: Morillo CA et al. JAMA 2014; 311: 692-699

Time to First Recurrence of Any Atrial Tachyarrhythmia (A) and Symptomatic Atrial Tachycardia (B)

From: Morillo CA et al. JAMA 2014; 311: 692-699

Number of Patients Without A. Fib in 7-day Holter

From: Nielson JC et al. NEJM 2012; 367: 1587-95

Overview of Management of Atrial Fibrillation

From: Prystowsky EN JAMA 2015, 314: 278-288