1. Home>
2. Specialties>
3. Cardiology>
4. Summary and Comment

First-Line Therapy for AFib: Catheter Ablation vs. Antiarrhythmic Drugs

The two approaches were compared in a randomized trial from Europe.

Catheter ablation, an effective treatment for highly symptomatic atrial fibrillation (AF), has generally been restricted to AF that is refractory to treatment with one or more antiarrhythmic drugs (AADs), because of the procedure's small but real potential for serious complications, including stroke, pulmonary-vein stenosis, tamponade, and esophageal perforation.

Now, in a randomized trial conducted at three centers in Italy and Germany, researchers have compared catheter-based pulmonary-vein isolation (PVI) with physician-guided AAD therapy in 70 adults (mean age, 54) with symptomatic monthly episodes of AF for at least 3 months; none had previously received AADs or undergone catheter ablation. Almost all patients (96%) had paroxysmal AF. The recommended AAD regimen was oral flecainide (100–150 mg) twice daily, propafenone (225–300 mg) 3 times daily, or sotalol (120–160 mg) twice daily. Loop-event-recorder monitoring was used during the first month after randomized-treatment initiation and again at month 3; Holter recordings were obtained at 3, 6, and 12 months.

At 1 year, the rate of recurrent symptomatic AF was significantly higher in the AAD group than in the PVI group (63% vs. 13%), as was the hospitalization rate (54% vs. 9%). No subjects experienced thromboembolic events or other major complications. Asymptomatic pulmonary-vein stenosis was documented in two patients (6%) in the PVI group; in neither case was the stenosis severe. Quality-of-life assessment at 6 months showed significantly greater improvements with PVI than with AAD therapy.

Comment: This small study provides preliminary evidence that catheter ablation might be superior to antiarrhythmic drugs as first-line therapy for symptomatic AF. The findings should help to prompt a much larger randomized trial. For now, catheter ablation should be considered only in patients with highly symptomatic, drug-refractory AF. This procedure is an evolving one, and many patients are best served by waiting for further improvements to it.

— Hugh Calkins, MD

Published in Journal Watch Cardiology July 8, 2005

Citation(s):

Wazni OM et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: A randomized trial. JAMA 2005 Jun 1; 293:2634-40.

• Original article (Subscription may be required)
• Medline abstract (Free)