What does this research mean for the field?

Catheter ablation in atrial fibrillation patients with a prior history of stroke significantly reduces the 5-year risk of recurrent stroke and death compared to no ablation, lowering their stroke risk to levels comparable to patients without atrial fibrillation. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

November 13, 2017Journal of Cardiovascular Electrophysiology

Five‐year impact of catheter ablation for atrial fibrillation in patients with a prior history of stroke

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Why the study?

Does catheter ablation reduce recurrent CVA, heart failure, and death in patients with atrial fibrillation and a prior history of stroke?

Structured PICO

Does catheter ablation reduce recurrent CVA, heart failure, and death in patients with atrial fibrillation and a prior history of stroke?

Population

971 patients with a prior history of stroke (CVA), average age 69 ± 11 years, 51% male. Comprised of AF patients receiving first ablation (n=139), AF patients without ablation (n=416), and CVA patients without clinical AF (n=416).

Intervention

Catheter ablation for atrial fibrillation (first ablation)

Comparator

AF patients that did not receive an ablation, and CVA patients without clinical AF (matched 1:3:3 by propensity score)

Outcome

Recurrent CVA, heart failure, and death at 5 yearshard clinical

Catheter ablation for atrial fibrillation in patients with a prior stroke is associated with a significantly lower 5-year risk of recurrent stroke and death compared to no ablation, reducing stroke risk to levels similar to patients without AF.

Implication

May support ablation consideration in post-stroke AF; leaves open causal confirmation by randomized trials.

Abstract

BACKGROUND: Catheter ablation of atrial fibrillation (AF) is an established therapeutic rhythm approach. Patients with a prior history of a stroke (CVA) represent a unique high-risk population for recurrent thromboembolic events. The role of antiarrhythmic treatment on the natural history of stroke recurrence in these patients is not fully understood. METHODS: Three patient groups with a prior CVA and 5 years of follow-up were matched 1:3:3 by propensity score (±0.01): AF ablation patients receiving their first ablation (n = 139), AF patients that did not receive an ablation (n = 416), and CVA patients without clinical AF (n = 416). Prior CVA was determined by medical chart review. Patients were followed for outcomes of recurrent CVA, heart failure, and death. RESULTS: The average age of the population was 69 ± 11 years and 51% male. AF ablation patients had higher rates of hypertension and heart failure (P < 0.0001), but diabetes prevalence was similar between the groups (P = 0.5). Note that 5-year risk of CVA (HR = 2.26, P < 0.0001) and death (HR = 2.43, P < 0.0001) were higher in the AF, no ablation group compared those that were ablated. When comparing AF, ablation to no AF patients, there was not a significant difference in 5-year risk of for CVA (HR = 0.82, P = 0.39) and death (HR = 0.92, P = 0.70); however, heart failure risk was increased (HR = 3.08, P = 0.001). CONCLUSION: In patients with AF and a prior CVA, patients undergoing ablation have lower rates of recurrent stroke compared to AF patients not ablated. Although the full mechanisms of benefit are unknown, as CVA rates are similar to patients without AF these data are suggestive of a potential altering of the natural history of disease progression.