Clinical Edge

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ATTEST: AFib ablation slows progression to persistence

Key clinical point: Catheter ablation of atrial fibrillation (AFib) was substantially more effective than was medical management for slowing paroxysmal to persistent arrhythmia progression.

Major finding: Catheter ablation of paroxysmal AFib cut progression to a persistent arrhythmia by 89%, compared with medical management.

Study details: ATTEST, a multicenter, randomized study with 255 patients.

Disclosures: ATTEST was funded by Biosense Webster, a company that markets catheter ablation devices. Dr. Kuck has been a consultant to Biosense Webster, as well as to Abbott, Boston Scientific, Edwards, and Medtronic.


Kuck K-H. ESC 2019 Congress.


The ATTEST design and results are important because the study’s findings provide a good complement to the previously reported outcomes from the CASTLE-AF study, which randomized 363 patients with mostly persistent AFib (and heart failure) to catheter ablation of the AFib or medical management. The CASTLE-HF results showed that ablation was much more effective for reducing death from any cause and heart failure hospitalizations (N Engl J Med. 2018 Feb 1;378[5]:417-27). In other words, catheter ablation was the superior treatment for persistent AFib, the type of AFib diagnosed in about two-thirds of the patients enrolled in CASTLE-AF.

In the results from ATTEST we see the benefit of radiofrequency catheter ablation for slowing or preventing progression of paroxysmal to persistent AFib. Preventing progression to persistent AFib is even more appealing than successfully treating persistent AFib. This additional benefit from ablation seen in ATTEST means that we should lower our threshold for offering patients catheter ablation for AFib. Data like those from ATTEST are propelling us to use ablation earlier in the AFib disease process. The value of ablation for slowing AFib progression is also being studied in the EAST (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) trial, which may report results in 2020. If EAST also shows benefits from early use of ablation on paroxysmal AFib, then the time will have arrived to use ablation not just to relieve symptoms of AFib but also to prevent or slow progression of the AFib and thereby improve patients’ prognosis.

Thorsten Lewalter, MD, an arrhythmia specialist and professor at Peter Osypka Heart Center in Munich, made these comments in an interview. He has received personal fees from Abbott, Bayer, Boehringer Ingelheim, Boston Scientific, Daiichi Sankyo, and Pfizer.