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