Ablation Versus Drugs: What Is the Best First-Line Therapy for Paroxysmal Atrial Fibrillation?Response to Colleen M. Hanley, MD, Douglas Esberg, MD, FACC, FHRS, Peter R. Kowey, MD, FAHA, FHRS
Antiarrhythmic Drugs Are Outmoded and Catheter Ablation Should Be the First-Line Option for All Patients With Paroxysmal Atrial Fibrillation: Con
Atrial fibrillation (AF) is the most common cardiac arrhythmia, with a lifetime risk exceeding 20% by 80 years of age.1 It 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 pre-existing cardiovascular conditions in the Framingham Heart Study.3 Despite these associations, antiarrhythmic drug (AAD) therapy with the goal of maintaining sinus rhythm has not improved outcomes in randomized trials.4,5 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 all-cause mortality but superior in reducing hospitalizations.6 No studies have shown a reduction in stroke or heart failure when rhythm control is attempted in patients with AF. If the patient has risk factors for thromboembolism, anticoagulation is maintained in either strategy. Therefore, the major reason to pursue sinus rhythm in patients with AF is to improve their symptoms and quality of life.
Response by Santangeli et al on p 754
During the past decade, attention has shifted from AADs toward catheter ablation. Catheter ablation was found to be superior to AAD therapy for maintaining sinus rhythm in many small, randomized trials of selected patients in whom treatment with an AAD had failed.7 Although these findings are intriguing, they require confirmation in a prospective randomized controlled trial. In addition, a benefit with respect to survival and morbidity has yet to be confirmed. Nonetheless, ablation is now regarded as an acceptable therapy for symptomatic patients who desire to remain in sinus rhythm and who have not had a response to ≥1 antiarrhythmic medication.4,5 But has ablation achieved sufficient safety and efficacy to …