Efficacy and safety of ablation in patients with non-paroxysmal atrial fibrillation


The optimal rhythm management strategy for people with non-paroxysmal ( persistent or long-standing persistent ) atrial fibrilation is currently not well defined.
Antiarrhythmic drugs have been the mainstay of therapy. But recently, in people who have not responded to antiarrhythmic drugs, the use of ablation ( catheter and surgical ) has emerged as an alternative to maintain sinus rhythm to avoid long-term atrial fibrillation complications.
However, evidence from randomised trials about the efficacy and safety of ablation in non-paroxysmal atrial fibrillation is limited.

The aim of the study was to determine the efficacy and safety of ablation ( catheter and surgical ) in people with non-paroxysmal ( persistent or long-standing persistent ) atrial fibrillation compared to antiarrhythmic drugs.

Researchers included randomised trials evaluating the effect of radiofrequency catheter ablation ( RFCA ) or surgical ablation compared with antiarrhythmic drugs in adults with non-paroxysmal atrial fibrillation, regardless of any concomitant underlying heart disease, with at least 12 months of follow-up.

Three randomised trials with 261 participants ( mean age: 60 years ) comparing RFCA ( n=159 ) to antiarrhythmic drugs ( n=102 ) for non-paroxysmal atrial fibrillation were included.

Evidence showed that radiofrequency catheter ablation was superior to antiarrhythmic drugs in achieving freedom from atrial arrhythmias ( risk ratios, RR 1.84, 95% CI 1.17 to 2.88; 3 studies, 261 participants; low-quality evidence ), reducing the need for cardioversion ( RR 0.62, 95% CI 0.47 to 0.82; 3 studies, 261 participants; moderate-quality evidence ), and reducing cardiac-related hospitalisation ( RR 0.27, 95% CI 0.10 to 0.72; 2 studies, 216 participants; low-quality evidence ) at 12 months follow-up.

There was substantial uncertainty surrounding the effect of radiofrequency catheter ablation regarding significant bradycardia ( or need for a pacemaker ) ( RR 0.20, 95% CI 0.02 to 1.63; 3 studies, 261 participants; low-quality evidence ), periprocedural complications, and other safety outcomes ( RR 0.94, 95% CI 0.16 to 5.68; 3 studies, 261 participants; very low-quality evidence ).

In people with non-paroxysmal atrial fibrillation, evidence suggests a superiority of radiofrequency catheter ablation to antiarrhythmic drugs in achieving freedom from atrial arrhythmias, reducing the need for cardioversion, and reducing cardiac-related hospitalisations.
There was uncertainty surrounding the effect of radiofrequency catheter ablation with significant bradycardia ( or need for a pacemaker ), periprocedural complications, and other safety outcomes.
Evidence should be interpreted with caution, as event rates were low and quality of evidence ranged from moderate to very low. ( Xagena )

Nyong J et al, Cochrane Database Syst Rev 2016; Epub ahead of print

XagenaMedicine_2016



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