First-line ablation averts AF progression

Among patients with paroxysmal atrial fibrillation (AF), initial treatment with cryoballoon ablation reduced the incidence of persistent AF through 3 years of follow-up compared with antiarrhythmic drug (AAD) therapy, according to the PROGRESSIVE-AF* trial presented at AHA 2022.

Patients first treated with ablation for paroxysmal AF had a 75-percent reduction in the risk of progressing to persistent AF compared with those who were initially treated with AAD. [AHA 2022, session LBS.08]

Specifically, only 1.9 percent of the patients in the ablation group experienced an episode of persistent AF vs 7.4 percent in the AAD group.

Persistent AF was defined in this study as AF episodes lasting ≥7 continuous days or lasting 48 hours to 7 days but requiring cardioversion for termination.

Lead author Dr Jason Andrade from Vancouver General Hospital in Vancouver, British Columbia, Canada, pointed out that despite enrolling a population of relatively young and healthy patients with very few comorbidities, who were objectively at low risk of progression, the findings still showed significant differences in the rates of disease progression between first-line ablation strategy and AAD therapy.

“We know that persistent AF is associated with worse clinical outcomes, including increased risk of death and rates of stroke and new-onset heart failure; hence, any intervention that could potentially decrease that progression would be of value,” he noted.

PROGRESSIVE-AF is a follow-up of the EARLY-AF** trial, which included 303 patients with untreated, symptomatic paroxysmal AF who were randomized to first-line cryoballoon ablation (n=154) or AADs*** (n=149). As previously reported, the risk of AF recurrence at 1 year as measured using implantable loop recorders was lower in the ablation group. [N Engl J Med 2021;384:305-315]

By 3 years, recurrence of any atrial tachyarrhythmia (defined as AF, atrial flutter, or atrial tachycardia lasting >30 seconds; one of the secondary endpoints) was significantly lower with first-line ablation therapy than with AAD therapy (56.5 percent vs 77.2 percent; hazard ratio, 0.51; p<0.0001).

These improvements in arrhythmia outcomes with first-line ablation led to improved quality of life (QoL) and reduced hospitalization and healthcare utilization.

Lower rates of AF burden and symptoms were also observed in the ablation group over the AAD group (0.0 percent vs 0.24 percent and 4.8 percent vs 17.1 percent, respectively) during the 3-year follow-up.

In terms of safety, overall adverse events were less frequent in the ablation arm (11 percent vs 23.5 percent), although the difference in serious events did not reach significance (4.5 percent vs 10.1 percent), Andrade said.

“Historically, the management of AF has largely been focused on improving symptoms and QoL,” Andrade said. “For the first time, we can definitively say that, in addition to enabling patients to live a fuller life, early intervention with catheter ablation is a disease-modifying procedure.”

However, the investigators cautioned that because the trial was performed with a single ablation technology, the observed outcomes may not be generalizable to other ablation energy sources. [N Engl J Med 2022;doi:10.1056/NEJMoa2212540]

*PROGRESSIVE-AF: The impact of "First-Line" rhythm therapy on AF progression

**EARLY-AF: Early Aggressive Invasive Intervention for Arial Fibrillation

***flecainide, propafenone, sotalol, dronedarone, or amiodarone