June 4, 2019European Heart Journal
Rhythm control for patients with atrial fibrillation complicated with heart failure in the contemporary era of catheter ablation: a stratified pooled analysis of randomized data
Key result
Catheter ablation improves survival and reduces rehospitalizations in AF patients with HF.
Why the study?
Does a rhythm control strategy using catheter ablation or antiarrhythmic drugs improve clinical outcomes in patients with atrial fibrillation complicated with heart failure?
Key Points
- To evaluate the efficacy and hard clinical safety endpoints of rhythm control strategies—antiarrhythmic drugs versus rate control and catheter ablation versus medical therapy—in patients with atrial fibrillation and heart failure.
- Conducted a stratified pooled analysis of 11 randomized trials including 3,598 patients with atrial fibrillation and heart failure.
- Stratified trials into Subset A comparing antiarrhythmic drug rhythm control against rate control (n=2,486) and Subset B comparing catheter ablation rhythm control against medical therapy (n=1,112).
- Evaluated primary endpoints of all-cause mortality, re-hospitalization, stroke, thromboembolic events, left ventricular ejection fraction, and arrhythmia recurrence.
- Antiarrhythmic drug rhythm control showed similar all-cause mortality (OR: 0.96, P=0.65) and stroke rates (OR: 0.91, P=0.76) compared to rate control, but significantly higher re-hospitalization rates (OR: 1.25, P=0.01).
- Catheter ablation significantly decreased all-cause mortality (OR: 0.51, P=0.0003) and re-hospitalization (OR: 0.44, P=0.003) compared to medical therapy, with similar stroke event rates (OR: 0.59, P=0.27).
- Catheter ablation produced greater improvements in left ventricular ejection fraction (WMD: 6.8%, P=0.0004), markedly lower arrhythmia recurrence (29.6% vs. 80.1%, OR: 0.04, P<0.00001), and improved quality of life scores (WMD: -9.1, P=0.007).
Structured PICO
Does a rhythm control strategy using catheter ablation or antiarrhythmic drugs improve clinical outcomes in patients with atrial fibrillation complicated with heart failure?
P
Population
3,598 patients with atrial fibrillation complicated with heart failure pooled from 11 randomized studies (Subset A: n=2,486; Subset B: n=1,112).
I
Intervention
Rhythm control strategy using either antiarrhythmic drugs (Subset A) or catheter ablation (Subset B).
C
Comparator
Rate control (Subset A) or medical therapy (Subset B).
O
Outcome
All-cause mortality, re-hospitalization, stroke, and thromboembolic events.hard clinical
Catheter ablation, but not antiarrhythmic drugs, as a rhythm control strategy significantly improves survival and reduces re-hospitalization in patients with concurrent atrial fibrillation and heart failure.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Despite the negative primary results of RAFT-AF most electrophysiologists including myself firmly believe that sinus rhythm is superior to AFib in patients in whom this goal can be achieved. Catheter ablation is superior to antiarrhythmic meds in achieving this goal. One cannot underestimate the importance of the quality of life benefits of catheter ablation shown in this trial. Furthermore, sinus rhythm achieved through catheter ablation has the potential to reduce long term stroke risk, reduce development of dementia, and reduce the progression of heart failure. And the end of the day, the message in my mind is that catheter ablation of AFib should be seriously considered in all CHF patients with a significant AFib burden.”
SSStavros StavrakisCardiac electrophysiologist, University of Oklahoma
“Based both on our meta-analysis and the CABANA data, patients with AFib most likely to benefit from ablation are patients younger than 65 and those with heart failure.”
Implication
Should increase catheter ablation adoption in AF-HF; reinforces superiority over medical therapy while challenging AAD efficacy in RCTs.
Abstract
AIMS: The optimal treatment for patients with atrial fibrillation (AF) and heart failure (HF) has been a subject of debate for years. We aimed to evaluate the efficacy and safety of rhythm control strategy in patients with AF complicated with HF regarding hard clinical endpoints. METHODS AND RESULTS: Up-to-date randomized data comparing rhythm control using antiarrhythmic drugs (AADs) vs. rate control (Subset A) or rhythm control using catheter ablation vs. medical therapy (Subset B) in AF and HF patients were pooled. The primary outcomes were all-cause mortality, re-hospitalization, stroke, and thromboembolic events. A total of 11 studies involving 3598 patients were enrolled (Subset A: 2486; Subset B: 1112). As compared with medical rate control, the AADs rhythm control was associated with similar all-cause mortality [odds ratio (OR): 0.96, P = 0.65], significantly higher rate of re-hospitalization (OR: 1.25, P = 0.01), and similar rate of stroke and thromboembolic events (OR: 0.91, P = 0.76,); however, as compared with medical therapy, catheter ablation rhythm control was associated with significantly lower all-cause mortality (OR: 0.51, P = 0.0003), reduced re-hospitalization rate (OR: 0.44, P = 0.003), similar rate of stroke events (OR: 0.59, P = 0.27), greater improvement in left ventricular ejection fraction [weighted mean difference (WMD): 6.8%, P = 0.0004], lower arrhythmia recurrence (29.6% vs. 80.1%, OR: 0.04, P < 0.00001), and greater improvement in quality of life (Minnesota Living with Heart Failure Questionnaire score) (WMD: -9.1, P = 0.007). CONCLUSION: Catheter ablation as rhythm control strategy substantially improves survival rate, reduces re-hospitalization, increases the maintenance rate of sinus rhythm, contributes to preserve cardiac function, and improves quality of life for AF patients complicated with HF.
Discussion
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Cite This Study
Chen et al. (2019) studied this question. Catheter ablation for rhythm control improves survival, reduces rehospitalization, maintains sinus rhythm, preserves cardiac function, and improves quality of life in AF patients with HF.