Recurrence of Atrial Fibrillation After Catheter Ablation or Antiarrhythmic Drug Therapy in the CABANA Trial
Jeanne E. PooleJeanne E. PooleTristram D. BahnsonKristi H. MonahanGeorge JohnsonHoss RostamiA SilversteinHussein R. Al‐KhalidiYves RosenbergDaniel B. MarkKerry L. LeeDouglas L. PackerJeanne E. PooleJeanne E. PooleNazem AkoumPierre S. AoukarUlrika Birgersdotter‐GreenJoseph BlattYong‐Mei ChaMina K. ChungMarye J. GlevaTaya V. GlotzerCharles HenricksonJack KronVikas KuriachanSiva K. MulpuruPeter A. NoseworthyKris PattonJordan M. PrutkinRavi RanjanRobert W. RhoAndrea M. RussoEric C. SteckerWendy S. TzouLaura Vitali SerdozMauri Wilson
Key result
Catheter ablation reduces AF recurrence by ~48% versus antiarrhythmic drug therapy.
- HR 0.52
- 95% CI 0.45-0.60
- P<0.001
- n=1,240
Why the study?
To assess recurrence of atrial fibrillation in patients randomized to catheter ablation versus antiarrhythmic drug therapy in the CABANA trial.
Does catheter ablation reduce recurrence of atrial fibrillation compared with antiarrhythmic drug therapy in patients with atrial fibrillation?
Key Points
- This study aims to evaluate the recurrence of atrial fibrillation in patients undergoing catheter ablation compared to those receiving antiarrhythmic drug therapy.
- Prospective study of CABANA trial patients utilizing an electrocardiogram monitor for AF detection.
- Analysis included 1,240 patients with post-blanking recordings for AF recurrence assessment.
- Used biannual Holter monitoring to evaluate AF burden over 60 months.
- First recurrence of any AF significantly reduced in the ablation group (HR: 0.52, 95% CI: 0.45 to 0.60, p < 0.001).
- First recurrence of symptomatic-only AF decreased significantly in the ablation group (HR: 0.49, 95% CI: 0.39 to 0.61, p < 0.001).
- AF burden at 12 months was 6.3% in ablation patients versus 14.4% in drug-therapy patients (p < 0.001).
Study Design
Type
RCT (n=1,240)
Structured PICO
Does catheter ablation reduce recurrence of atrial fibrillation compared with antiarrhythmic drug therapy in patients with atrial fibrillation?
P
Population
1,240 patients with atrial fibrillation (paroxysmal in 43.0%) who used CABANA monitors and provided 90-day post-blanking recordings, median age 68 years, 34.4% women.
I
Intervention
Catheter ablation
C
Comparator
Antiarrhythmic drug therapy
O
Outcome
First recurrence of any symptomatic or asymptomatic AF (any post-90-day blanking atrial tachyarrhythmias lasting 30 s or longer)surrogate
Main Result
Effect estimate: HR 0.52 (95% CI 0.45-0.60)
p-value: p=<0.001
Catheter ablation significantly reduces the recurrence and burden of atrial fibrillation compared to antiarrhythmic drug therapy over 5 years of follow-up.
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“These data support the finding of smaller trials that catheter ablation is superior to drug therapy to prevent recurrent AF. CABANA was the largest trial conducted comparing a strategy of ablation to drug therapy, and across a broad group of patients with cardiovascular comorbidities. Our findings support catheter ablation as an important strategy which can be offered to patients with AF.”
“Most commonly, we look at clinical trial data by comparing the results according to which group a patient is randomly assigned, but patients and physicians do not always follow the assigned treatment. When we examined the data according to the treatment actually received, the ablation group had significantly lower rates of death as well as the combination of death, disabling stroke, serious bleeding, or cardiac arrest compared with patients who only received drug therapy.”
“The CABANA trial report on late AF recurrence confirms the clear benefit of catheter ablation vs. pharmacological therapy in preventing recurrent AF in patients with symptomatic AF, and is important in being”
Implication
Supports ablation over drugs for AF rhythm control; confirms smaller trials within largest RCT cohort.
Abstract
CABANA randomized 2204 patients with atrial fibrillation (AF) to catheter ablation or drug therapy. Analysis by intention-to-treat (ITT), showed a non-significant 14% relative reduction in the primary outcome of death, disabling stroke, serious bleeding, or cardiac arrest. To assess recurrence of atrial fibrillation (AF) in The Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) We prospectively studied CABANA patients using a proprietary ECG recording monitor for symptom-activated and 24-hour AF auto detection. The AF recurrence endpoint was any post 90-day blanking atrial tachyarrhythmias lasting 30 seconds or longer. Ninety-six-hour Holter monitoring obtained biannually was used to assess AF burden. Patients using the CABANA monitors and provided 90-day post-blanking recordings qualified for this analysis (1240, 56% of CABANA population). Treatment comparisons were performed using a modified- ITT approach. Median age of the 1240 patients was 68 years, 34.4% women, and AF was paroxysmal in 43.0%. Over 60 months of follow-up, first recurrence of any symptomatic or asymptomatic AF (hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.45, 0.60, P <0.001) or, first symptomatic-only AF (HR 0.49, 95% CI 0.39, 0.61, P <0.001) were both significantly reduced in the catheter ablation group. Baseline Holter AF burden in both treatment groups was 48%. At 12 months, AF burden in ablation patients averaged 6.3%, and in drug therapy patients, 14.4%. AF burden was significantly less in catheter ablation compared with drug therapy patients across the 5-year follow-up ( P <0.001). These findings were not sensitive to the baseline pattern of AF. Catheter ablation was effective in reducing recurrence of any AF by 48% and symptomatic AF by 51% as compared to drug therapy over 5 years of follow-up. Furthermore, AF burden was also significantly reduced in catheter ablation patients, regardless of their baseline AF type.
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Cite This Study
Poole et al. (2020) conducted an RCT in Atrial fibrillation (n=1,240). Catheter ablation vs. Antiarrhythmic drug therapy was evaluated on First recurrence of any symptomatic or asymptomatic atrial fibrillation (post-90-day blanking atrial tachyarrhythmias lasting ≥30 s) (HR 0.52, 95% CI 0.45-0.60, p=<0.001). Catheter ablation significantly reduced the first recurrence of any symptomatic or asymptomatic atrial fibrillation compared with antiarrhythmic drug therapy (HR 0.52; 95% CI 0.45-0.60; p<0.001).