Clinical question: How does radiofrequency ablation compare to antiarrhythmic therapy as first-line treatment for paroxysmal atrial fibrillation (AF)?
Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines support radiofrequency ablation in high-volume centers for select patients with symptomatic, paroxysmal AF who have failed antiarrhythmic therapy (Class I recommendation). Little data exist regarding catheter ablation as a first-line intervention.
Study design: Randomized prospective cohort study.
Setting: Multicenter Danish trial.
Synopsis: Investigators randomized patients with symptomatic paroxysmal AF who were deemed to be good candidates for rhythm control to antiarrhythmic therapy versus radiofrequency catheter ablation. Patients had seven-day Holter monitoring at three, six, 12, 18, and 24 months. There was no significant difference in the cumulative burden of AF between the antiarrhythmic and ablation groups (19% and 13%, respectively; P=0.10). Secondary outcomes including quality of life and cumulative burden of symptomatic AF did not vary significantly between the groups. Crossover was high, with 35% of patients randomized to antiarrhythmic therapy eventually undergoing catheter ablation during the trial. There was no statistically significant difference in adverse events between the two groups.
This trial lends credence to the current ACC/AHA guidelines recommending radiofrequency ablation as second-line therapy for patients with AF after failing antiarrhythmics.
Bottom line: Radiofrequency ablation and antiarrhythmic therapy have similar efficacy as first-line therapy in paroxysmal AF.
Citation: Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587-1595.
