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Radiofrequency ablation an option for healthy younger patients with paroxysmal AF

Clinical Question:
For patients with paroxysmal atrial fibrillation, is an initial strategy of radiofrequency ablation better than drug therapy?

Bottom Line:
This study found that over a 2-year period, there was a modest increase in the likelihood of being free of symptomatic atrial fibrillation (AF; number needed to treat [NNT] = 11) in patients randomized to receive radiofrequency ablation (RA) instead of medical therapy. However, the procedure has uncommon but devestating complications (as do, of course, drugs like amiodarone) and we do not know whether the treatment effect persists, prevents the development of long-term complications such as stroke, or is associated with reduced long-term mortality. Trials are underway to answer these questions. Until then, RA is an option for carefully selected patients (ie, young and without major comorbidities) who are determined to hang on to that old sinus rhythm as long as possible. For others, remember that rate control is a good option (N Engl J Med 2008;358:2667-2677; POEM #100804). (LOE = 1b)

Cosedis Nielsen J, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 2012;367(17):1587-1595.  [PMID:23094720]

Study Design:
Randomized controlled trial (nonblinded)

Industry + govt


Outpatient (specialty)

Previous studies have found similar (or better) results for rate control with appropriate anticoagulation versus rhythm control for patients with AF. However, for younger patients who are more symptomatic, rhythm control may be desired. This study randomized 294 patients with a mean age of 55 years to RA or drug therapy. None were older than 70 years and none had major heart disease. The drug therapy arm began with flecainide or propafenone, and if those were not tolerated, amiodarone or sotalol were used. Other agents could be added, plus cardioversion, to try and maintain the patient in normal sinus rhythm. Patients underwent 7-day Holter monitoring at 3, 6, 12, 18 and 24 months, and they were advised to seek care if they had palpitations or other cardiovascular symptoms. Patients in the RA group underwent a mean of 1.6 procedures, and approximately one third in the medical therapy group underwent RA, which would dampen any potential benefit of the procedure. At the end of the 24-month study, the percentage of time spent in AF (9% vs 18%; P = .007), the percentage free of AF (85% vs 71%; P = .004; NNT = 7), and the percentage free of symptomatic AF (93% vs 84%; P = .01; NNT = 11) were better in the RA group. These differences were not statistically significant at 6, 12, or 18 months. The authors report that the physical component of quality of life improved more in the RA group, but this difference was not statistically significant. Adverse effects occurred in both groups, but were more serious in the RA group, including 1 death due to a periprocedural stroke and 3 episodes of cardiac tamponade.


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