Background: Catheter ablation of AFib (primarily pulmonary vein isolation) has been shown to result in better maintenance of sinus rhythm than medications. Small studies of QOL have shown mixed results. Larger trials were needed.
Dr. Neil Stafford
Study design: Open-label randomized multisite clinical trial of catheter ablation (pulmonary vein isolation with additional ablation procedure at the treating physician discretion) versus standard rate and/or rhythm control medications (chosen by clinician discretion). Patients were included for paroxysmal or persistent AFib and either age 65 years or older or age younger than 65 years with one additional stroke risk factor. Quality of life surveys – the Atrial Fibrillation Effect on Quality of Life (AFEQT) questionnaire and the Mayo AF-Specific Symptom Inventory (MAFSI) – were completed at baseline, and at 3, 12, 24, 36, 48, and 60 months.
Setting: 126 centers in 10 countries.
Synopsis: The study included 2,204 patients with median age of 68 years, diagnosed with AFib a median of 1.1 years prior, who were followed for a median of 48 months. The median CHA2DS2-VASc score was 3.0.
Self-reported AFib dropped from 86.0% to 21.1% in the ablation group and from 83.7% to 39.8% in the medication group at 12 months. The AFEQT score (range 0-100, higher score indicating better QOL) increased from 62.9 to 86.4 in the ablation group and increased from 63.1 to 80.9 in the medication group (for a mean difference of 5.3 points [95% confidence interval, 3.7-6.9; P less than .001] favoring ablation). MAFSI symptom frequency score and symptom severity score also showed improvement in symptoms favoring ablation. Post hoc subgroup analysis showed that those with the most severe symptoms had the largest benefit from ablation.
The primary limitation is the lack of patient blinding (may bias self-reported symptoms).
While the CABANA trial efficacy study (published separately) showed that catheter ablation results in no significant difference in the combined outcome of death, disabling stroke, serious bleeding, or cardiac arrest, the CABANA QOL study, reviewed here, shows that ablation does result in improved QOL and reduced symptoms, compared with medical therapy.
Bottom line: Catheter ablation of AFib can be done safely and successfully at experienced centers. In patients with AFib-related symptoms, ablation reduces symptoms and improves QOL somewhat more than medications do. The most severely symptomatic patients appear to obtain the most benefit.
Citation: Packer DL et al. Effect of catheter ablation vs. antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019 Mar 15. doi: 10.1001/jama.2019.0693.
Dr. Stafford is a hospitalist at Duke University Health System.