When is catheter ablation a sound option for your patient with A-fib?
Ablation sits far along on the spectrum of atrial fibrillation therapy, where its indications and potential efficacy call for careful consideration.
PRACTICE RECOMMENDATIONS
› Refer patients with atrial fibrillation (AF) to Cardiology for consideration of catheter ablation, a recommended treatment in select cases of (1) symptomatic paroxysmal AF in the setting of intolerance of antiarrhythmic drug therapy and (2) persistence of symptoms despite antiarrhythmic drug therapy. A
› Continue long-term oral anticoagulation therapy post ablation in patients with paroxysmal AF who have undergone catheter ablation if their CHA2DS2–VASc score is ≥ 2 (men) or ≥ 3 (women). C
› Regard catheter ablation as a reasonable alternative to antiarrhythmic drug therapy in select older patients with AF, and refer to a cardiologist as appropriate. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Notably, direct studies comparing ablation and AAD have not confirmed the benefit of ablation over AAD in outcomes of all-cause mortality, bleeding, stroke, or cardiac arrest over a 5-year period.8
Adverse effects and mortality outcomes with AAD. Concern over using AAD for rhythm control is based mostly on adverse effects and long-term (1-year) mortality outcomes. Long-term AAD therapy has been shown to decrease the recurrence of AF—but without evidence to suggest other mortality benefits.
A meta-analysis of 59 randomized controlled trials reviewed 20,981 patients receiving AAD (including quinidine, disopyramide, propafenone, flecainide, metoprolol, amiodarone, dofetilide, dronedarone, and sotalol) for long-term effects on death, stroke, adverse reactions, and recurrence of AF.9 Findings at 10 months suggest that:
- Compared to placebo, amiodarone and sotalol increased the risk of all-cause mortality during the study period.
- There was minimal difference in mortality among patients taking dofetilide or dronedarone, compared to placebo.
- There were insufficient data to draw conclusions about the effect of disopyramide, flecainide, and propafenone on mortality.
Before starting a patient on AAD, the risk of arrhythmias and the potential for these agents to cause toxicity and adverse events should always be discussed.
CASE
You tell Mr. Z that you need to know the status of his comorbidities to make a recommendation about “other” management options, and proceed to take a detailed history.
Recent history. Mr. Z reveals that “today is a good day”: He has had “only 1” episode of palpitations, which resolved on its own. The previous episode, he explains, was 3 days ago, when palpitations were associated with lightheadedness and shortness of breath. He denies chest pains or swelling of the legs.
Physical exam. The patient appears spry, comfortable, and in no acute distress. Vital signs are within normal limits. A body mass index of 28.4 puts him in the “overweight” category. His blood pressure is 118/75 mm Hg.
Continue to: Cardiac examination...
