Should Ablation Be First-Line Therapy and for Whom: The Antagonist Position

Abstract

Atrial fibrillation (AF), the commonest cardiac arrhythmia with an adverse prognosis, has an estimated prevalence of 0.4% in general population.1 The disease is associated with significant morbidity related to symptoms, heart failure, and thromboembolism.2 Although AF is generally considered a non–life-threatening arrhythmia, it was associated with a 1.5- to 1.9-fold excess mortality after adjustment for preexisting cardiovascular conditions in the Framingham Heart Study.3 In the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study, a strategy of heart rate control was equivalent to heart rhythm control in terms of quality of life and all-cause mortality but superior in reducing hospitalizations.4 Anticoagulation with warfarin is maintained in either strategy if the patient has risk factors for thromboembolism. The major reason to pursue sinus rhythm in patients with AF is to improve their symptoms and quality of life. No studies have shown a reduction in stroke or heart failure when rhythm control is attempted in patients with AF. Once the decision to achieve rhythm control in a given patient has been made, physicians have to determine the best means of achieving this objective. Multiple randomized trials have demonstrated a modest but highly significant efficacy for antiarrhythmic medications.5 The limited long-term efficacy and high incidence of side effects of antiarrhythmic medications have prompted physicians to consider nonpharmacological therapies for AF.6 It has also been postulated, in a retrospective subanalysis of the AFFIRM study, that a strategy to maintain sinus rhythm without the adverse effects of antiarrhythmic medications may confer a survival advantage.7 In a nonrandomized study, Pappone et al8 compared the outcomes in a selected group of 589 patients who underwent circumferential pulmonary vein ablation with 582 age- and gender-matched cohort patients who received antiarrhythmic medications to maintain sinus rhythm. After a median follow-up of …