Ablation as first-line treatment cuts AF progression compared to antiarrhythmic drugs

Jason Andrade

Ablation as a first-line treatment for atrial fibrillation (AF) disease is associated with significantly better clinical outcomes than starting with antiarrhythmic drugs.

These were the findings of the 36-month PROGRESSIVE-AF trial, presented by Jason Andrade (Vancouver General Hospital, Vancouver, Canada) at the American Heart Association scientific sessions (5–7 November, Chicago, USA) and published in the New England Journal of Medicine 

Andrade described how the authors looked to investigate whether catheter ablation could improve AF outcomes when used as a first rather than second-line treatment. The primary endpoint was progression to persistent AF, while secondary endpoints included arrhythmia-recurrence, quality-of-life and hospitalisation. 

Andrade began by outlining how atrial fibrillation begins episodically before progressing to become persistent. Persistent AF is associated with worse clinical outcomes, he noted, including increased risk of death, stroke and heart failure. Andrade said that “any intervention which could potentially decrease that progression would be of value.”  

The trial enrolled and randomised 303 AF patients from 18 centres before comparing outcomes among 154 randomised to ablation as a first-line treatment, using Medtronic’s Arctic Front cardiac cryoablation catheter, and 149 who started with AAD. To consistently measure heart rhythm in the patients selected for the trial, the authors used an implantable loop recorder, the presenter shared with delegates.

They found first-line ablation coincided with a 75% reduction in progression to persistent AF even though the patient population was relatively young with few comorbidities. Ablation patients experienced improved quality-of-life compared with AAD after three years, assessed through the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) survey and EuroQol (EQ-5D). 

Patients treated with the investigational strategy saw a huge comparative reduction in hospitalisation risk, with 5.2% of ablation-treated patients hospitalised compared with 16.8% with AAD. There was also a 51% reduction in tachyarrhythmia recurrence compared with AAD after three years. Importantly, ablation was associated with >50% less adverse outcomes compared to AAD.

“On the whole these results demonstrate consistent benefit with first-line ablation. Not only does ablation reduce arrhythmia episodes, improve quality of life, and reduce healthcare utilisation, but we now know that ablation is a disease-modifying therapy,” Andrade told Cardiac Rhythm News. “While AADs treat the symptoms of AF, ablation treats the disease by preventing the progression to more advanced forms of AF.” 

Discussant at the AHA conference talk, Carina Blomström Lundqvist (Institution of Medical Science, Uppsala, Sweden) stated that it was “a limitation [of the study] that baseline AF burden was not assessed,” meaning, she added, that patients’ AF progression could only be compared against one another’s, rather than relative to the starting point of their own condition. She concluded that, given that other treatments do remain effective, “the optimal patient and timing for a first-line ablation is yet unclear.” 


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