Perspective from Gerald V. Naccarelli, MD
Source:

Healio Commentary

Disclosures: Granger reports receiving consultant honoraria and/or research grant support from AbbVie, Alnylam, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Celecor, Daiichi Sankyo, Eli Lilly, Hengrui, Janssen, Medtronic, Merck, the NIH, Novartis, Novo Nordisk, Philips, Pfizer, Reata and the FDA.
January 27, 2022
4 min read
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Early referral for ablation may be needed for certain patients with AF

Perspective from Gerald V. Naccarelli, MD
Source:

Healio Commentary

Disclosures: Granger reports receiving consultant honoraria and/or research grant support from AbbVie, Alnylam, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Celecor, Daiichi Sankyo, Eli Lilly, Hengrui, Janssen, Medtronic, Merck, the NIH, Novartis, Novo Nordisk, Philips, Pfizer, Reata and the FDA.
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By 2030, the number of people in the United States with atrial fibrillation will double to more than 12 million, making it imperative that patients receive the best treatments to improve outcomes and functional status.

For controlling the rhythm for symptomatic patients with AF, drug therapy has been the standard of care, but antiarrhythmic drugs are failing in more than half of patients. Only after drugs have failed will many patients go on to have a catheter ablation. Because AF can limit a person’s ability to carry on with daily activities, like climbing the stairs or walking down the driveway to the mailbox, delaying a patient’s time to ablation not only allows for disease progression but may reduce their overall quality of life.

Graphical depiction of source quote presented in the article
Christopher B. Granger, MD, is professor of medicine at Duke University School of Medicine and member in the Duke Clinical Research Institute.

Comprehensive treatment of AF with oral anticoagulation, addressing comorbidities, rate control and rhythm control are essential to improving symptoms, preventing stroke and HF, reducing hospitalizations and improving survival. The evidence for the timing and type of rhythm control has advanced over the past few years.

Shifting the paradigm in AF treatment

Looking back just 2 or 3 years ago, the way I treated patients with AF was completely different. I considered ablation to be a last resort or an option only for those with recurring symptoms after antiarrhythmic drug treatment. Now, for the first time, the results of three randomized clinical trials — Cryo-FIRST, EARLY-AF and STOP AF First — provide clear evidence for how and when to best control rhythm: they show that ablation and, particularly, cryoablation — ablation with a cryoballoon catheter (Arctic Front Advance, Medtronic) — as a first-line treatment is a proven, evidence-based initial rhythm control strategy to reduce atrial arrhythmia recurrence and improve patient outcomes. In June, the FDA granted a new indication to cryoballoon catheter ablation, permitting it to be used before antiarrhythmic drugs in certain patients with AF.

As a general cardiologist, I see a broad spectrum of patients every week with symptoms of AF. This includes friends, colleagues and members of my community, and for each one of them, I now can confidently present ablation, including cryoablation, as the most effective treatment to maintain sinus rhythm and improve their quality of life, even before trying any antiarrhythmic drug therapy.

For many of my patients, the journey of AF care with ablation begins with some type of monitoring device. For example, a woman at Duke in her mid-60s originally received a heart monitor to track her heart palpitations. She called me one night because she was presenting with symptoms and sent me her rhythm strips, which showed AF on her device for hours at a time. After a conversation about creating a treatment plan, I referred her to get an ablation — ultimately leaving her feeling assured knowing we caught the disease early and that she was on course for the most effective treatment. Within 4 months of when her symptoms began, she received an ablation and is getting back to her everyday life.

Managing misconceptions

To achieve these better outcomes for patients and offer the best course of care possible, it is important to understand how the management of AF has changed over the last several years, address the misconceptions that exist, and educate on why ablation, and in particular cryoablation, is a safe and effective initial treatment option:

  • Many symptomatic patients will benefit from an initial rhythm control strategy: Compared with previous notions, there has been mounting evidence over the past few years that show a rhythm control strategy provides benefits to prevent ongoing and worsening symptoms for patients with symptomatic AF. This is also consistent with the 2020 European Society of Cardiology Clinical Practice Guidelines for Atrial Fibrillation.
  • Ablation is quite safe: Recent evidence shows us that current state-of-the-art ablation, including cryoablation, is not only effective but has few complications. Now safety concerns are a minimal barrier for considering ablation as the first step in a patient’s treatment course.
  • Ablation is the optimal initial strategy for many patients: Ablation should not just be a backup strategy for patients who tried multiple drugs or cardioversions. We now have evidence for ablation as the best initial strategy for maintaining sinus rhythm and improving quality of life.
  • Monitoring technology has dramatically improved: With the latest monitoring technology, including use of consumer devices to record AF, we can now determine if patients with symptoms of AF have substantial AF much faster than before. With today’s improved AF detection solutions, combined with cryoablation as an initial treatment strategy, our patients have the potential to see better outcomes related to faster diagnosis compared with several years ago.

Early referral for many symptomatic patients

It is important that we communicate clearly to patients about the best treatment options early after diagnosis of AF. As general cardiologists, this means having conversations with our patients about how to manage their condition, depending on their symptoms and burden of AF.

For the millions of patients with AF that we see in our practice as general cardiologists, we have the ability to guide them to the best care to improve their quality of life and to prevent hospitalizations. As a key part of the referral process, it is important to take a team-based approach, with referral of the patient with recent-onset symptomatic AF to electrophysiology colleagues who can offer ablation for the many patients for whom this is the best initial treatment option.

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Christopher B. Granger, MD, is professor of medicine at Duke University School of Medicine and member in the Duke Clinical Research Institute. He can be reached at grang001@mc.duke.edu.