8/9/2016 Conflict of Interest When to Consider Antiarrhythmic Drugs vs Catheter Ablation • Consultant: Medtronic; Abbott EP; Stereotaxis; CardioNet • Board of Directors: Stereotaxis Eric N Prystowsky, MD Director, Cardiac Arrhythmia Service, • Stock: Stereotaxis St Vincent Hospital, Indianapolis, IN • Institutional Fellowship support: Boston Consulting Professor of Medicine, Scientific; Medtronic; St Jude Duke Univ Medical Center AFFIRM Enrollment Screened When to Consider Sinus N = 7401 Declined Rhythm vs Rate Control n = 3341(45%) Enrolled N = 4060 Status Unknown Withdrew n = 26 n = 71 Follow-up N = 3963 AFFIRM Investigators NEJM 2002; 347:1825-33 1
8/9/2016 Rate Versus Rhythm Control in Patients with “Documented” Safety of A. Fib (AFFIRM) Persistent Atrial Fibrillation 62 72 0 100 AGE From: AFFIRM investigators NEJM 2002; 347:1825 Effect on Rhythm vs. Rate Control Therapy Long-term Outcomes in Patients With AF; AF/RFA; on Mortality Over Time No AF History From: Bunch TJ et al. J Cardiovasc Electrophysiol 2011; 22: From: Ionescu-Ittu R et al. Arch Intern Med 2012; 172: 997 839 2
8/9/2016 Cognitive Function Evaluation in Controls (green), Paroxysmal AF (blue) and Persistent AF (red) If there was a safe and effective method to restore and maintain sinus rhythm, would you allow your patient to remeain in atrial fibrillation? From: Gaita et al., JACC 2013; 21: 1990-7 Patient N-56 HPI: 47-year-old man presents for a second opinion regarding recently diagnosed A. Fib. (CHADS-VAS c = 0). He was at routine yearly PCP visit and asymptomatic and A. Fib was diagnosed Sinus rhythm: A bridge to the with HR > 120/min. His last exam was a year ago and without A. Fib. Future 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 3
8/9/2016 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 of life • Neither ablation nor antiarrhythmic drug therapy decides whether a patient receives anticoagulation 4
8/9/2016 Results from Randomized Trials of Catheter Ablation vs. Antiarrhythmic Drug Therapy in Atrial Fibrillation From: Prystowsky EN JAMA 2015, 314: 278-288 Inhospital Complications Associated with Ablation of A. Fib Strategies for Rhythm Control in Patients in USA, 2000-2010 (n=93,801) with Paroxysmal and Persistent AF • 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% From: 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation, Circulation, March 28, 2014 From: Deshmukh, Circulation 9/23/13 (online) 5
8/9/2016 Catheter ablation as first line Percent Complication Rate by Annual Operator Volume 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 From: Deshmukh, Circulation 9/23/13 (online) Proposed Treatment Algorithm for Paroxysmal and Persistent Atrial Fibrillation Back up slides From: Prystowsky EN JAMA 2015, 314: 278-288 6
8/9/2016 Radiofrequency Ablation vs. Antiarrhythmic Drugs as Time to First Recurrence of Any Atrial Tachyarrhythmia (A) and First-line Therapy for Paroxysmal AF (RAAFT-2) Symptomatic Atrial Tachycardia (B) • 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 From: Morillo CA et al. JAMA 2014; 311: 692-699 Number of Patients Without A. Fib in 7-day Holter Overview of Management of Atrial Fibrillation From: Nielson JC et al. NEJM 2012; 367: 1587-95 From: Prystowsky EN JAMA 2015, 314: 278-288 7
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