SHA24/026005

Treatment of AF: Drugs vs Ablation

Panos Ε. Vardas Prof. of Cardiology, ESC President, Heraklion University Hospital, Crete

Declaration of Conflict of Interest

Modest consultancy fees from

Bayer, Boehringer Ingelheim Bristol Myers Squibb, Medtronic Menarini, Servier

What Are the Goals of AF Therapy? Improve survival Reduce sequelae

 Stroke, systemic emboli, heart failure Reduce hospitalizations Improve symptoms Improve QoL Restore process

atrial

function/reverse

the

remodeling

Minimize adverse effects of therapies employed

AF: Current Treatment Options Rate control

Pharmacologic • Ca2+ blockers ∀ β-blockers • Digitalis • Amiodarone Nonpharmacologic • Ablate and pace

Maintenance of SR

Stroke prevention

Pharmacologic Nonpharmacologic Pharmacologic

Class IA Catheter ablation Class IC Surgery (MAZE) Class III Pacing β-blocker

Prevent remodeling ACE-I ARB

• • • •

Warfarin Thrombin inhibitor Heparin Aspirin

Nonpharmacologic • Removal / isolation LA appendage

Treatment Dilemmas

 Is Rhythm better than Rate control?  Is AF ablation better than AADs in maintenance of SR?  Do we need anticoagulants after AF ablation?

Anti-Arrhythmic Therapy Rate or Rhythm control?

PIAF

STAF

AFFIRM

RACE

HOT CAFE

Pts

252

200

4060

522

205

F-u (mo)

12

22

42

27

20

Age

60

65

70

68

61

Persistent

Persistent/ Paroxysmal

Persistent/ Recurrent after ECV

Persistent

However‌

AF

Persistent

Therapies

Am-ECV

Am-Prop-Fl-ECV

Am-Sot-PropECV

Sot-Fl-Prop-AmECV

Am-Sot-Prop

Endpoint

Symptoms

Comp clinical events

Death

Comp clinical events

Comp clinical events

Results

No differ

No differ

No differ

No differ

No differ

None of these trials demonstrated the expected superiority of the rhythm control strategy

The original AFFIRM STUDY

One year later…

AFFIRM revisited…

AFFIRM revisited…

AFFIRM revisited…

Treatment Dilemmas

 Is Rhythm better than Rate control?  Is AF ablation better than AADs in maintenance of SR?

 

Efficacy Safety

 Do we need anticoagulants after AF ablation?

Efficacy of AAD to maintain SR is modest‌

…and this will not change in the near future

PALLAS study

AF Ablation Era microcircuits of reentry Sueda

Ann Thorac Surg 1997

critical fibres Hwang

Circulation 2000

focal triggers Haissaguerre NEJM 1998

Catheter Ablation Versus Antiarrhythmic Drugs for Atrial Fibrillation The A4 Study

Kaplan-Meier analysis for time to recurrent AF after the 90-day treatment adjustment period for both groups Jais, P. et al. Circulation 2008;118:24982505

Catheter Ablation Versus Antiarrhythmic Drugs for Atrial Fibrillation The A4 Study ď ą Symptom

score,

exercise

capacity, and quality of life were significantly higher in the ablation group ď ą Catheter ablation is superior to antiarrhythmic drugs in patients with AF with regard to

maintenance

of

sinus

rhythm and improvement in symptoms,

exercise

capacity, and quality of life

Catheter Ablation versus Antiarrhythmic Drugs for AF

Tung R et al. Circulation 2012;126:223-229

Treatment Dilemmas

 Is Rhythm better than Rate control?  Is AF ablation better than AADs in maintenance of SR?

 

Efficacy Safety

 Do we need anticoagulants after AF ablation?

AF Ablation Major Complications

Cappato . Circ Arrhythm Electrophysiol. 2010

Periprocedural death Tamponade Sepsis, abscesses, or endocarditis Pneumothorax Hemothorax Permanent diaphragmatic paralysis Femoral pseudoaneurysm Arterovenous fistulae Valve damage Atrium-esophageal fistulae Stroke Transient ischemic attack PV stenoses requiring intervention TOTAL

25

0.15

213

1.31

2

0.01

15

0.09

4

0.02

28

0.01

152

0.17

88

0.54

11/7

0.07

6

0.04

37

0.23

115

0.71

48

0.29

741

4.54 %

AF Ablation Major Complications

AAD vs Catheter Ablation: Safety issues AAD therapy

Calkins et al Circ Arrhythmia Electrophysiol. 2009

Catheter ablation

When is left AF ablation recommended?

Camm JA, et al. al. Eur Heart J 2012 2012

When is left AF ablation recommended?

Circulation 2011;123:e269-367

When is left AF recommended?

Circulation 2011;123:e269-367

Catheter ablation of AF: who are the best Candidates?

Treatment Dilemmas

 Is Rhythm better than Rate control?  Is AF ablation better than AADs in maintenance of SR?

 

Efficacy Safety

 Do we need anticoagulants after AF ablation?

Anticoagulation in AF Ablation Era

 Initially post-ablation, LMWH or i.v. UFH should be used as a bridge to resumption of systemic anticoagulation, which should be continued for a minimum of 3 months  Thereafter, the individual stroke risk of the patient should determine whether oral anticoagulation should be continued  Discontinuation of warfarin therapy post-ablation is generally not recommended in patients at risk for stroke Camm et al. Eur Heart J 2010

“Data try out for a prospective, randomized clinical trial that includes standardized methods of follow-up to assess and characterize recurrence of AF and to determine the incidence/ prevalence of stroke.

Conclusion: do not stop the warfarin until we have prospective, randomized clinical trials that can help guide us in providing anticoagulation therapy for our patients.�

Cakulev I, Waldo A. JACC 2010

Conclusions

ď ą Guidelines provide detailed recommendations for the management of patients with AF ď ą Anticoagulation is essential in AF patients with risk markers, regardless of any restoration of SR ď ą In the absence of new antiarrhythmics with an improved benefit/risk profile, AF ablation is becoming a first-line strategy for certain patient populations