Key result
Continuing previously ineffective antiarrhythmic drugs after catheter ablation for persistent AF did not reduce atrial tachyarrhythmia recurrence compared to discontinuation (21.2% vs 20.0%).
Why the study?
In patients with persistent AF, catheter ablation aiming for pulmonary vein isolation has moderate effectiveness, leaving unclear the benefit of continuing previously ineffective antiarrhythmic drug therapy after standardized PVI-only ablation.
Does continuing previously ineffective antiarrhythmic drug therapy reduce atrial tachyarrhythmia recurrence in patients with persistent atrial fibrillation undergoing pulmonary vein isolation?
RCT (n=200)
1:1
Yes
Does continuing previously ineffective antiarrhythmic drug therapy reduce atrial tachyarrhythmia recurrence in patients with persistent atrial fibrillation undergoing pulmonary vein isolation?
Answers are grounded in this paper and cite their sources.
Continuing previously ineffective antiarrhythmic drug therapy beyond the blanking period after optimized pulmonary vein isolation does not reduce atrial tachyarrhythmia recurrence in patients with early-stage persistent atrial fibrillation.
BACKGROUND: In patients with persistent atrial fibrillation (PersAF), catheter ablation aiming for pulmonary vein isolation (PVI) is associated with moderate clinical effectiveness. We investigated the benefit of continuing previously ineffective class 1C or 3 antiarrhythmic drug therapy (ADT) in the setting of a standardized PVI-only ablation strategy. METHODS: In this multicenter, randomized controlled study, patients with PersAF (≥7 days and <12 months) despite ADT were prospectively randomized 1:1 to PVI with ADT continued versus discontinued beyond the blanking period (ADT ON versus ADT OFF). Standardized catheter ablation was performed aiming for durable isolation with stable, contiguous, and optimized radio frequency applications encircling the pulmonary veins (CLOSE protocol). Clinical visits and 1-to-7-day Holter were performed at 3, 6, and 12 months. The primary end point was any documented atrial tachyarrhythmia lasting >30 seconds beyond 3 months. Prospectively defined secondary end points included repeat ablations, unscheduled arrhythmia-related visits, and quality of life among groups. RESULTS: Of 200 PersAF patients, 98 were assigned to ADT OFF and 102 to ADT ON. The longest atrial fibrillation episode qualifying for PersAF was 28 (10-90) versus 30 (11-90) days. Clinical characteristics and procedural characteristics were similar. Recurrence of atrial tachyarrhythmia was comparable in both groups (20% OFF versus 21.2% ON). No differences were observed in repeat ablations and unscheduled arrhythmia-related visits. Marked improvement in quality of life was observed in both groups. CONCLUSIONS: In patients with PersAF, there is no benefit in continuing previously ineffective ADT beyond the blanking period after catheter ablation. The high success rate of PVI-only might be explained by the high rate of durable isolation after optimized PVI and the early stage of PersAF (POWDER-AF2). REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03437356.
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Demolder et al. (2023) conducted an RCT in persistent atrial fibrillation (PersAF) (n=200). Continued antiarrhythmic drug therapy (ADT ON) vs. Discontinued antiarrhythmic drug therapy (ADT OFF) was evaluated on any documented atrial tachyarrhythmia lasting >30 seconds beyond 3 months. Continuing previously ineffective antiarrhythmic drugs after catheter ablation for persistent AF did not reduce atrial tachyarrhythmia recurrence compared to discontinuation (21.2% vs 20.0%).
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