Clinical question: Does initial therapy with catheter cryoballoon ablation reduce progression to persistent atrial fibrillation (AF) in patients with symptomatic, paroxysmal AF when compared to antiarrhythmic therapy?
Background: Atrial fibrillation can progress from a paroxysmal to a persistent form due to electrical and structural remodeling of the heart. The Early Aggressive Invasive Intervention for Atrial Fibrillation (Early-AF) trial concluded that initial treatment of symptomatic, paroxysmal AF with cryoballoon ablation resulted in lower recurrence of arrhythmias compared to antiarrhythmic drug therapy alone during one year of follow-up. However, it was unclear if catheter cryoballoon ablation reduced progression to persistent AF compared to antiarrhythmic therapy.
Study design: Multicenter, open-label, randomized trial with blinded end-point adjudication
Setting: 18 centers in Canada
Synopsis: Patients with symptomatic, paroxysmal AF were randomly assigned to rhythm control with either cryoballoon ablation (n=154) or antiarrhythmic drug therapy (n=149). All 303 patients had an implantable loop recorder placed. Crossover between groups was restricted and all patients received their assigned strategy before the primary endpoint event. Patients were followed for 36 months with the primary endpoint being the first occurrence of persistent AF. Secondary outcomes included arrhythmia burden, quality of life, health care utilization (defined as emergency department visits), hospitalizations, cardioversion or non-protocol ablation, and serious adverse events defined as death, functional disability, or new or prolonged existing hospitalization.
After 36 months, three patients (1.9%) in the ablation group developed persistent AF compared to 11 patients (7.4%) in the antiarrhythmic drug group. Recurrent atrial tachyarrhythmia affected 87 patients (56.5%) in the ablation group and 115 patients (77.2%) in the antiarrhythmic drug group. The ablation group was associated with lower AF burden, improved quality of life, lower health care utilization, and less serious adverse events when compared to the antiarrhythmic drug group.
Bottom line: In treatment-naïve patients with symptomatic, paroxysmal atrial fibrillation, cryoballoon ablation should be utilized as an initial strategy to delay progression to persistent atrial fibrillation, as opposed to antiarrhythmic therapy.
Citation: Andrade JG, et al. Progression of atrial fibrillation after cryoablation or drug therapy. N Engl J Med. 2023;388(2):105-16.
Dr. Allen
Dr. Duggirala
Drs. Allen and Duggirala are clinical associate professors in the division of hospital medicine at The Ohio State University Wexner Medical Center in Columbus, Ohio