Chapter 4: Evidence for the Early Use of Ablation and AADs Post-Ablation

Both catheter ablation and antiarrhythmic drugs (AADs) are effective treatments for atrial fibrillation (AF) and can be used individually or as complementary treatments. This chapter discusses the use of ablation for early rhythm control in AF, and the use of AADs post-ablation. Decisions on which therapeutic approach to pursue should be based on shared decision-making with the patient. The chapter reviews data from the CABANA trial, in which the intent-to-treat (ITT) analysis failed to show superiority for ablation versus AADs. Statistical significance was achieved, however, when using the pre-specified per-protocol and pre-treatment analyses. The discussion addresses the fact that data analysis was complicated by several factors: (1) not all members of the group assigned to ablation actually received ablation; (2) the AAD arm included rate control treatment without the use of AADs; (3) there were a large number of crossovers from the AAD arm to the ablation arm; and (4) many ablation-treated participants also used AADs. Results from the CABANA trial showed that ablation was better at preventing AF recurrence than AADs alone. Data from the STOP AF and EARLY AF trials that support the observation of ablation being superior to AADs alone for the reduction of recurrent AF are also reviewed. Many patients who undergo catheter ablation for AF either continue to use or need to restart AADs following ablation. This combination therapy is used by up to 40–50% of people at 1-year post ablation, as is clearly demonstrated by the results from the trials discussed above, in addition to those from the 5A trial, the POWDER AF trial, the AMIO-CAT trial, and a substantial meta-analysis. All these trials are reviewed in this chapter, noting that a variety of differences exist between the randomized clinical trials, including in ablation procedures, follow-up periods, physician experience, and AADs. Chapter 4 is summarized as follows:(1)AADs and ablation both have important roles in treating AF early after diagnosis and should be considered as complementary rather than competitive treatments.(2)A shared decision-making conversation between the patient and the physician should drive the decision on whether to pursue an ablation or AAD approach for rhythm control.(3)The use of AADs after ablation appears to reduce the risk of AF recurrence and hospitalization; however, further research is needed to clarify the role of this treatment approach and to determine the patient populations who would derive most benefit from it. Both catheter ablation and antiarrhythmic drugs (AADs) are effective treatments for atrial fibrillation (AF) and can be used individually or as complementary treatments. This chapter discusses the use of ablation for early rhythm control in AF, and the use of AADs post-ablation. Decisions on which therapeutic approach to pursue should be based on shared decision-making with the patient. The chapter reviews data from the CABANA trial, in which the intent-to-treat (ITT) analysis failed to show superiority for ablation versus AADs. Statistical significance was achieved, however, when using the pre-specified per-protocol and pre-treatment analyses. The discussion addresses the fact that data analysis was complicated by several factors: (1) not all members of the group assigned to ablation actually received ablation; (2) the AAD arm included rate control treatment without the use of AADs; (3) there were a large number of crossovers from the AAD arm to the ablation arm; and (4) many ablation-treated participants also used AADs. Results from the CABANA trial showed that ablation was better at preventing AF recurrence than AADs alone. Data from the STOP AF and EARLY AF trials that support the observation of ablation being superior to AADs alone for the reduction of recurrent AF are also reviewed. Many patients who undergo catheter ablation for AF either continue to use or need to restart AADs following ablation. This combination therapy is used by up to 40–50% of people at 1-year post ablation, as is clearly demonstrated by the results from the trials discussed above, in addition to those from the 5A trial, the POWDER AF trial, the AMIO-CAT trial, and a substantial meta-analysis. All these trials are reviewed in this chapter, noting that a variety of differences exist between the randomized clinical trials, including in ablation procedures, follow-up periods, physician experience, and AADs. Chapter 4 is summarized as follows:(1)AADs and ablation both have important roles in treating AF early after diagnosis and should be considered as complementary rather than competitive treatments.(2)A shared decision-making conversation between the patient and the physician should drive the decision on whether to pursue an ablation or AAD approach for rhythm control.(3)The use of AADs after ablation appears to reduce the risk of AF recurrence and hospitalization; however, further research is needed to clarify the role of this treatment approach and to determine the patient populations who would derive most benefit from it. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhZWJlZWQ2MjU2YWQyMTU1Mzk4MTcxMmY2ZDI4ZWVhOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk5ODIzMTgzfQ.W7lwOQIOEPrL-q_dE8QW5HiFwFO9_xjuZ7uHOc-2lGWLzjnV6ZddDDBwuWuJBGWqtQBqe1eEX_dRHJRK4x7ZJbAsDsb9HqVwbzMbev0C_YxOC6ENXFJL6jMCC84ZX4oI-w1YKFZFti9J6hUetUtfKTtej6XfbuyM_AKwtcFmngs4Ko-1OjIRNdbwXNl6QTwfAWs4cCgwbfB6uZ5nof5CiDatRizAbBo3pqyjjMfHatzSDnEJjZlyWHuJC7H0t3p0V4XyO7TAacdT46ZHaCRBjjGwSOHplQo0_1XZ4S69KdQHnHxr-WxurR0mGrKAbJzpJ2L2vu2kNl4SxFiPiAGfkw(mp4, (26.44 MB) Download video eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhZWJlZWQ2MjU2YWQyMTU1Mzk4MTcxMmY2ZDI4ZWVhOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk5ODIzMTgzfQ.W7lwOQIOEPrL-q_dE8QW5HiFwFO9_xjuZ7uHOc-2lGWLzjnV6ZddDDBwuWuJBGWqtQBqe1eEX_dRHJRK4x7ZJbAsDsb9HqVwbzMbev0C_YxOC6ENXFJL6jMCC84ZX4oI-w1YKFZFti9J6hUetUtfKTtej6XfbuyM_AKwtcFmngs4Ko-1OjIRNdbwXNl6QTwfAWs4cCgwbfB6uZ5nof5CiDatRizAbBo3pqyjjMfHatzSDnEJjZlyWHuJC7H0t3p0V4XyO7TAacdT46ZHaCRBjjGwSOHplQo0_1XZ4S69KdQHnHxr-WxurR0mGrKAbJzpJ2L2vu2kNl4SxFiPiAGfkw(mp4, (26.44 MB) Download video Thomas F. Deering, MD, MBA, FHRS, FACC, FACP Dr. Thomas F. Deering is a cardiac electrophysiologist at Piedmont Heart Institute in Atlanta where he serves as Chief of the Arrhythmia Center and Chief Quality Officer. In addition he serves as Chair of the Cardiovascular Governance Center for Piedmont Healthcare. He has served in a variety of volunteer roles for the Heart Rhythm Society (HRS),most recently as president between May 2018 and May 2019 and currently the chair of the Quality Improvement Committee. His research and clinical interests are focused on implementing quality initiatives in electrophysiology and cardiovascular medicine. He has served as a speaker and moderator at national and international electrophysiology and cardiology meetings; has authored and co-authored numerous publications addressing cardiac arrhythmia and cardiovascular quality issues; participates as an investigator and principal investigator in a number of cardiac electrophysiology arrhythmia research projects and serves as an editor and reviewer for multiple cardiac electrophysiology and general cardiac journals. Dr. Deering earned his medical degree from Yale University School of Medicine. He completed his residency at the Yale-New Haven Hospital, his cardiology fellowship training at Boston University Medical Acesion and his cardiac electrophysiology fellowship at Tufts New England Medical Center. He has previously been a Clinical Associate Professor of Medicine at Yale University School of Medicine and at present is a Clinical Associate Professor of Medicine at the Medical College of Georgia and the Mark E. Silverman, M.D. Educational Chair. James A. Reiffel, MD FACC, FAHA, FHRS, FESC, FACP, member EHRA Dr James A. Reiffel is Professor Emeritus of Medicine and Special Lecturer, Columbia University Vagelos College of Physicians and Surgeons; and Attending Physician [Emeritus] at The Presbyterian Hospital in New York City; Department of Medicine, Division of Cardiology, Section of Electrophysiology. During his career, Dr. Reiffel:•Has been actively involved in teaching, research, and clinical practice for over 4 decades.•Has had an active practice in consultative clinical cardiology and cardiac electrophysiology.•Has served as Director of the Clinical Electrophysiology Laboratory and the Electrocardiography Lab at the Columbia University-New York Presbyterian Medical Center.•Has taught regionally, nationally, and internationally – having given over 1000 invited presentations at most major medical institutions in the country and at several lay programs and on radio and TV as well.•Has been author or co-author of over 500 medical publications as well as 2 children's books and 1 golf book.•Has served on the editorial board of several medical journals and actively does peer-review for many more.•Has served in advisory capacities re: the FDA and multiple pharmaceutical and medical device companies and has been on planning committees for the Cardiac Safety Research Consortium.•Has been involved in developmental/research studies of electrophysiological techniques, antiarrhythmic pharmaceuticals and devices, new anticoagulants, and multiple major multicenter trials. Finally, Dr. Reiffel is a member of the Steering Committee for both the CABANA trial and the ORBIT AF Registries, was the principal investigator for the recently completed REVEAL AF trial, and co-principal investigator for the recently reported HARMONY trial. Dr. Reiffel is also on the Steering Committee of the HEARTLINE trial. Dr. Reiffel also serves on the Board of Directors of the Loggerhead Marinelife Center in Juno Beach, FL. and on the Board of Advisors of the Sarah P. Duke Gardens at Duke University in Durham, NC. Allen J. Solomon, M.D Dr. Allen J. Solomon is a Professor of Medicine in the Division of Cardiology at The George Washington University School of Medicine. He completed his medical school training at the University of Maryland School of Medicine in 1984. Then, he completed training in Internal Medicine, including a Chief Resident year, at the University of Maryland Hospital. Following this, he completed fellowship training in Cardiovascular Medicine and Cardiac Electrophysiology at Georgetown University Medical Center. In 1992 he joined the Division of Cardiology at Georgetown University, where he became the Director of the Electrophysiology service, as well as the Director of the Cardiology Fellowship Program. In 2004, he moved to The George Washington University Hospital, where he has continued his work as the Chief of the Electrophysiology service and the fellowship program. Dr. Solomon is currently Board certified in Internal Medicine, Cardiovascular Medicine, and Cardiac Electrophysiology. He has also won multiple teaching awards, including the American College of Cardiology (ACC) Teaching Award. Additionally, he has authored book chapters and more than 60 manuscripts. Finally, he has participated in several atrial fibrillation trials. Kamala P. Tamirisa, MD, FHRS, FACC, MAHA Dr. Kamala P. Tamirisa is a clinical cardiac electrophysiologist and cardiac MR imaging specialist, at Texas Cardiac Arrhythmia, in Dallas, TX. She developed the Cardio-Obstetrics Program for Medical City Hospitals in the Dallas area, and focuses on the management of arrhythmias, and cardiomyopathy in pregnancy. Before relocating to Texas, she served as the Outpatient Electrophysiology Director for ProMedica Physicians Cardiology in Northwest Ohio. She was the Co-Director of Education/Training, and the Physician Director for continued medical education. She also served as the Board Member, ProMedica Heart and Vascular Institute and was a member of the Electrophysiology Quality Initiatives. She started the high-risk Cardio-Obstetrics Program in Ohio, which expanded to a very successful program. She is the principal investigator/co-principal investigator for several trials and has authored blogs and scientific articles. Her special interests are disparities in electrophysiology clinical care, and arrhythmias in pregnancy. She is the lead author for the Journal of American College of Cardiology Electrophysiology State of the Art review on Arrhythmias in Pregnancy. Sheis the Chair for HRS Diversity, Equity, and Inclusion Council and a member of the HRS Social Responsibility Task Force. She served on the HRS Digital Health Committee and HRSTv sub-committee. She serves as the ACC Women in Cardiology (ACC WIC) Leadership Council member, ACC WIC Advocacy Co-Chair, ACC Cross-Sectional Advocacy Committee Member, ACC Electrophysiology Leadership Council Member and ACC Electrophysiology Advocacy Workgroup Chair. She is the host for the ACC WIC Practice Made Perfect Podcast and an invited speaker in multiple webinars and podcasts at the national level. She has given numerous lectures at local and the national/international platforms. She enjoys teaching. She is a mentor and a sponsor to many via HRS/ACC/Industry programs. Her passion to close the gaps in clinical cardiovascular care is evident from her community work in local gyms, shelters, safe houses, and inner-city salons. For these efforts, she received the HealthCare Heroes Award in Northwest Ohio and was nominated for the prestigious Thomas Jefferson Service Award. The article was published as part of a supplement supported by Sanofi. The authors received writing and editorial support in the preparation of the materials provided by Barrie Anthony, PhD, CMPPTM, of Evidence Scientific Solutions, funded by Sanofi.