Atrial Fibrillation Heart Heart Failure Research Stroke/TIA

Surgery first vs. drugs for A-Fib could stop disease’s progress: NEJM study

A study published today in the prestigious New England Journal of Medicine concludes treating the heart condition atrial fibrillation with surgery first, instead of drugs, can stop the disease from getting worse.

The study, whose principal investigator is St. Paul’s Hospital cardiac electrophysiologist, Dr. Jason Andrade, shows that initially using a surgical procedure to treat atrial fibrillation is associated with a lower rate of disease progression, better health outcomes and higher quality of life.

A-Fib, as it’s known, causes a chaotic and irregular heartbeat. People with it have a higher risk of stroke and premature mortality, and those risks increase as the disease gets more severe.

There are two options for treating A-Fib – medicines that normalize the heart rhythm, called antiarrhythmic drugs, or a surgical procedure called catheter ablation, which destroys the heart cells responsible for the irregular rhythm.

“The goal of catheter ablation is to prevent the electrical signals that trigger the atrial fibrillation from causing the arrhythmia to come back. Effectively we are building road blocks in the heart to prevent the atrial fibrillation,” says Dr. Andrade, also a cardiac electrophysiologist at Vancouver General Hospital.

Surgery as first treatment could reduce disease progression

Usually, the antiarrhythmic drugs would be used as the first line of treatment, and catheter ablation would be done if that was unsuccessful.

This study, which also included St. Paul’s Dr. Marc Deyell and Dr. Sandra Lauck, investigated whether catheter ablation may have better outcomes if it is performed as the first treatment. Waiting until the antiarrhythmic drugs have failed to perform catheter ablation inevitably delays the procedure until the disease is more advanced.

“If we perform the procedure earlier, the thinking was that maybe we could change that disease trajectory. We could prevent people from having these more advanced forms of atrial fibrillation, and so the procedure will not only work better, but it will change how people are living with the disease and lead to much better long-term outcomes,” says Dr. Andrade.

Dr. Jason Andrade, principal investigator

The study looked at the difference in disease progression between the two treatments by comparing two randomized groups out of a cohort of 303 people who were treated for atrial fibrillation – one that had the procedure as their first treatment, and one that had the medicine for a first treatment. The researchers implanted a cardiac monitor after treatment began to continuously track changes in heart rhythm over the three-year follow-up period.

Better patient outcomes means fewer hospital visits

One significant finding was that catheter ablation led to many fewer recurrences of atrial fibrillation than the antiarrhythmic drugs. This led to a better quality of life for the patient and lower subsequent health care utilization – patients who had catheter ablation went to the hospital or emergency room less often afterward. Doing the surgical procedure first had better outcomes from both a patient perspective and a health system perspective.

This study builds off an earlier study, which was a one-year follow-up with the same group of patients.

Both look at differences in the reoccurrence of atrial fibrillation and the impact on quality of life between the two treatments. The current study also examines how the disease progressed.

It found a 75-per-cent reduction in the progression from early to later forms of atrial fibrillation in patients who had the procedure, while the patients on medication continued to have more advanced forms of the disease. This is because while the medicine treats the symptoms, it doesn’t alter the progression of the disease.

Dr. Marc Deyell
Dr. Marc Deyell

Surgery reduced adverse effects

“By doing the procedure, you really got at the source of the problem and prevented people from developing more advanced forms of the disease over several years of follow-up,” says Dr. Andrade. “We know that the more advanced forms of atrial fibrillation have higher rates of stroke, are more likely to cause heart failure, and result in premature mortality. We’ve now shown for the first time that an intervention in the form of catheter ablation changes the disease trajectory and prevents patients from going on to have those more advanced forms of atrial fibrillation.”

Additionally, the study shows that patients in the ablation group had fewer serious adverse events than those the medicine group – 4.5 per cent versus 10.1 per cent, respectively. The procedure itself takes about an hour and a half, and most patients go home the same day and feel back to normal in about a week.

Dr. Sandra Lauck

Standard drugs not always benign

“I think a big finding of the study is that the standard of drugs aren’t necessarily as benign as people think, and we now have an intervention that changes the trajectory of the disease and can make things much better in the long run,” says Dr. Andrade.

In the future, more research is needed to see if this reduction in progression rates eventually translates into lower rates of stroke and heart failure, and overall better health outcomes.

Story by Grace Jenkins