Catheter ablation vs antiarrhythmic drug therapy for atrial fibrillation
Sübutlu məlumatların xülasələri
17.08.2017 • Sonuncu dəyişiklik 17.08.2017
Editors
Catheter ablation for atrial fibrillation appears to increase freedom from atrial arrhythmias at 12 months compared with antiarrhythmic drug therapy.
The quality of evidence is downgraded by inconsistency (variability in results).
Summary
A Cochrane review included 3 studies with a total of 261 subjects (mean age 60 years). The aim of the review was to determine the efficacy and safety of ablation (catheter and surgical) in people with non-paroxysmal (persistent or long-standing persistent) atrial fibrillation compared to antiarrhythmic drugs. All studies included participants that had not responded to antiarrhythmic drug therapy. Radiofrequency catheter ablation (RFCA) increased the proportion of patients achieving freedom from atrial arrhythmias (RR 1.84, 95% CI 1.17 to 2.88; 3 studies, n=261), reduced the need for cardioversion (RR 0.62, 95% CI 0.47 to 0.82; 3 studies, n=261), and reduced cardiac-related hospitalisation (RR 0.27, 95% CI 0.10 to 0.72; 2 studies, n=216) at 12 months follow-up compared to antiarrhythmic drugs. There was substantial uncertainty on the effect of RFCA regarding significant bradycardia (or need for a pacemaker) (RR 0.20, 95% CI 0.02 to 1.63; 3 studies, n=261), periprocedural complications, and other safety outcomes (RR 0.94, 95% CI 0.16 to 5.68, statistical heterogeneity I2=54%; 3 studies, n=261).
Another Cochrane review included 32 studies with a total of 3 560 subjects with paroxysmal or persistent AF. Catheter ablation (CA) compared with medical therapies had a better effect in inhibiting recurrence of AF (RR 0.27, 95% CI 0.18 to 0.41; 7 studies, n=760) but there was significant heterogeneity (I2=72%). There was limited evidence to suggest that sinus rhythm was restored during CA (RR 0.28, 95% CI 0.20 to 0.40; 1 study, n=198), and at the end of follow-up (RR 1.87, 95% CI 1.31 to 2.67; I2=83%; 4 studies, n=526). There were no differences in mortality (RR 0.50, 95% CI 0.04 to 5.65; 1 study, n=137), fatal and non-fatal embolic complication (RR 1.01, 95% CI 0.18 to 5.68; 2 studies, n=167) or death from thrombo-embolic events (RR 3.04, 95% CI 0.13 to 73.43; 1 study, n=137). 25 studies compared CA of various kinds. Circumferential pulmonary vein ablation was better than segmental pulmonary vein ablation in improving symptoms of AF (p<=0.01) and in reducing the recurrence of AF (p<0.01). There was limited evidence to suggest which ablation method was the best.
A Cochrane review included 32 studies with a total of 3 560 subjects. Catheter ablation (CA) compared with medical therapies had a better effect in inhibiting recurrence of AF (RR 0.27, 95% CI 0.18 to 0.41; 7 studies, n=760 ) but there was significant heterogeneity (I2=72% ). There was limited evidence to suggest that sinus rhythm was restored during CA (RR 0.28, 95% CI 0.20 to 0.40; 1 study, n=198), and at the end of follow-up (RR 1.87, 95% CI 1.31 to 2.67; I2=83%; 4 studies, n=526). There were no differences in mortality (RR 0.50, 95% CI 0.04 to 5.65; 1 study, n=137), fatal and non-fatal embolic complication (RR 1.01, 95% CI 0.18 to 5.68; 2 studies, n=167) or death from thrombo-embolic events (RR 3.04, 95% CI 0.13 to 73.43; 1 study, n=137). 25 studies compared CA of various kinds. Circumferential pulmonary vein ablation was better than segmental pulmonary vein ablation in improving symptoms of AF (p<=0.01) and in reducing the recurrence of AF (p<0.01). There was limited evidence to suggest which ablation method was the best.A systematic review including 6 studies with a total of 693 subjects was abstracted in DARE. Efficacy and safety of pulmonary vein isolation (PVI) was compared with medical therapy for the maintenance of sinus rhythm in subjects with atrial fibrillation (AF). The primary end point was freedom from recurrent AF at 12 months. PVI was compared with a nonablation treatment strategy; 5 studies compared PVI with antiarrhythmic drug therapy and 1 study (enrolling patients with persistent AF only) compared PVI and cardioversion followed by 3 months of amiodarone therapy in both arms. Of the patients included in the meta-analysis, 70% had paroxysmal AF. The mean age was 55 years. Among the 3 studies reporting preenrollment antiarrhythmic drug failure, the mean number of prior ineffective antiarrhythmic drugs before enrollment was 2. By definition, patients enrolled in 1 study had never received antiarrhythmic drug therapy before enrollment. In 1 study, patients were mandated to have failed at least 1 antiarrhythmic drug before enrollment.
PVI was associated with markedly increased odds of freedom from AF at 12 months of follow-up (266/344 [77%] versus 102/346 [29%]; OR 9.74, 95% CI 3.98 to 23.87; statistical heterogeneity I2=80.4). When the trial that only enrolled patients with persistent AF was excluded, PVI was associated with even greater odds of AF-free survival (OR 15.78, 95% CI 10.07 to 24.73). PVI was associated with a decreased hospitalization for cardiovascular causes (14 versus 93 per 100 person-years; RR 0.15, 95% CI 0.10 to 0.23). Among those randomly assigned to PVI, 17% required a repeat PVI ablation before 12 months. The rate of major complications was 2.6% (9/344) in the catheter ablation group and included tamponade, symptomatic pulmonary vein stenosis, pericardial effusion, phrenic nerve paralysis, and thromboembolic events. The rate of major complications for the patients who received antiarrhythmic medication was 8%, including pro-arrhythmia with flecainide, thyroid dysfunction secondary to amiodarone, sexual impairment, gastroenterological impairment, corneal micro-deposits, abnormal liver function tests, and sinus node dysfunction caused by amiodarone.
Comment: This meta-analysis did not evaluate PVI as a first-line treatment for symptomatic AF and these findings may not apply to older patients, patients with multiple comorbidities, patients with congestive heart failure caused by systolic or diastolic dysfunction, or patients with significant left atrial enlargement because these patients were not included in the studies. The observed complication rate was lower than in previous studies and probably reflects the expertise of the centers participating in the trials.A controlled nonrandomized Italian long-term study (median follow-up 900 days) examined the clinical course of 1 171 consecutive patients with symptomatic AF; 589 ablated patients were compared with 582 who received antiarrhythmic medications for sinus rhythm control. The quality of life (QoL) of 109 ablated and 102 medically treated patients was measured with the SF-36 survey. Kaplan-Meier analysis showed observed survival for ablated patients was longer than among patients treated medically (p < 0.001), and not different from that expected for healthy persons of the same gender and calendar year of birth (p = 0.55). Cox proportional-hazards model revealed in the ablation group hazard ratios of 0.46 (95% CI 0.31 to 0.68) for all-cause mortality, of 0.45 (95% CI 0.31 to 0.64) for morbidities mainly due to heart failure and ischemic cerebrovascular events, and of 0.30 (95% CI 0.24 to 0.37) for AF recurrence. Ablated patients' QoL, different from patients treated medically, reached normative levels at six months and remained unchanged at one year.
Ədəbiyyat
- "?>Nyong J, Amit G, Adler AJ et al. Efficacy and safety of ablation for people with non-paroxysmal atrial fibrillation. Cochrane Database Syst Rev 2016;(11):CD012088. Pappone C, Rosanio S, Augello G et al. Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study. J Am Coll Cardiol 2003;42(2):185-97.
- Chen HS, Wen JM, Wu SN et al. Catheter ablation for paroxysmal and persistent atrial fibrillation. Cochrane Database Syst Rev 2012;(4):CD007101.