Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long-term outcomes
Section snippets
Background
Many patients who develop atrial fibrillation (AF) will experience a worsening of their arrhythmia over time. Initially AF is trigger driven, typically from the pulmonary veins. Over time diverse mechanisms in isolation and combination result in an atrial myopathy with electrical, structural, and contractile changes.1, 2 Many of these structural changes in the atrium are arrhythmogenic and result in extrapulmonary vein triggers and circuits. These changes are often manifest by more frequent
Patient populations
Patients who received their catheter ablation for AF at an Intermountain Healthcare hospital (LDS Hospital and Intermountain Medical Center, Salt Lake City, UT; McKay Dee Hospital, Ogden, UT; Dixie Regional Medical Center, St. George, UT; and Utah Valley Regional Medical Center, Provo, UT) were evaluated. The study was approved by the Intermountain Healthcare Urban Central Institutional Review Board. Patients included in the study were those who resided within the region of these hospitals and
Results
We identified 4535 patients who had consistent long-term care through our system network. Table 1 lists the baseline demographics of these patients stratified by time from first known AF diagnosis until the time an AF ablation was performed recursive partitioning categories. For the complete study group, the mean days from AF diagnosis to first ablation was 818 ± 1218 days. Table 2 gives the long-term outcomes of these patients listed and compared by their time from diagnosis of AF to their
Discussion
This study has several important clinical findings. First, as the primary objective of the study, delays in treatment of AF by catheter ablation over time reduce procedural success. This is most apparent in those patients who undergo an ablation very early. However, the outcomes differences based upon delay strata continue to separate over time. Some of these temporal findings can be explained by an AF population that naturally ages but also develops more coexistent cardiovascular disease
Study limitations
These data are observational and as such provide intriguing findings regarding the role of catheter ablation but cannot provide the conclusions of a randomized trial of stratified delays in management. We relied on the first clinical diagnosis of AF in our system, but we may have missed earlier events outside of our system. We tried to minimize this risk by only including patients with consistent and long-term care through our health care network. However, missed events for both the first and
Conclusion
Delays in treatment with catheter ablation impact procedural success rates. AF outcomes such as heart failure and death are also worsened in patients in whom treatment was delayed. These data in aggregate suggest catheter ablation should be considered early in the AF disease process.
References (31)
- et al.
Temporal patterns of paroxysmal atrial fibrillation following DDDR pacemaker implantation
Am J Cardiol
(2000) - et al.
Real-life observations of clinical outcomes with rhythm- and rate-control therapies for atrial fibrillation RECORDAF (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation)
J Am Coll Cardiol
(2011) - et al.
Clinical predictors and relationship between early and late atrial tachyarrhythmias after pulmonary vein antrum isolation
Heart Rhythm
(2008) - et al.
Predictors of success after selective pulmonary vein isolation of arrhythmogenic pulmonary veins for treatment of atrial fibrillation
Heart Rhythm
(2006) - et al.
Structural changes of atrial myocardium during chronic atrial fibrillation
Cardiovasc Pathol.
(2000) Changes in left atrial size in patients with persistent atrial fibrillation: a prospective echocardiographic study with a 5-year follow-up period
Int J Cardiol
(2005)- et al.
Efficacy, safety and outcome of catheter ablation for atrial fibrillation in octogenarians
Int J Cardiol
(2010) - et al.
Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function
J Am Coll Cardiol
(2004) - et al.
Pathophysiological mechanisms of atrial fibrillation: a translational appraisal
Physiol Rev
(2011) - et al.
Electrical, contractile and structural remodeling during atrial fibrillation
Cardiovasc Res
(2002)
Long-term progression and outcomes with aging in patients with lone atrial fibrillation: a 30-year follow-up study
Circulation
Prevention of atrial fibrillation after cardioversion: results of the PAFAC trial
Eur Heart J
Amiodarone versus sotalol for atrial fibrillation
N Engl J Med
Predictors of atrial fibrillation recurrence after radiofrequency catheter ablation: a systematic review
J Cardiovasc Electrophysiol
Successful radiofrequency ablation in patients with previous atrial fibrillation results in a significant decrease in left atrial size
Circulation
Cited by (65)
Patterns of care for first-detected atrial fibrillation: Insights from the Get With The Guidelines® – Atrial Fibrillation registry
2022, Heart RhythmCitation Excerpt :While rate control with pharmacotherapy aims at symptomatic improvement related to rapid ventricular rates, rhythm control with antiarrhythmic drugs, cardioversion, or ablation targets the maintenance of sinus rhythm, which can potentially halt the progression of AF to more persistent forms. There is increased interest in the treatment of first-detected AF as time from diagnosis has been identified as an important prognostic marker in AF.8–11 However, the optimal management of patients with an initial episode of AF remains unclear.
Evidence to Support Rhythm Control Is Superior to Rate Control as Treatment for Atrial Fibrillation
2022, JACC: Clinical ElectrophysiologyDiagnosis-to-ablation time predicts recurrent atrial fibrillation and rehospitalization following catheter ablation
2022, Heart Rhythm O2Citation Excerpt :Few studies have assessed the association between DAT and “hard” cardiovascular outcomes, and the results are conflicting. For example, Bunch and colleagues13 found that longer DAT was associated with an almost 3-fold increased risk of all-cause mortality and 2-fold increased risk of HF hospitalization at 1 year. In contrast, another study found no significant differences in all-cause mortality or HF hospitalization after adjustment for baseline covariates, except in the subgroup of patients with a history of HF.14
Atrial Fibrillation Clinics: The Way of the Future
2022, Heart Lung and CirculationInitial rhythm control with cryoballoon ablation vs drug therapy: Impact on quality of life and symptoms
2021, American Heart Journal
Dr. Bunch is/has been a consultant (minor) to Biosense Webster, St. Jude Medical, and Boston Scientific; Research from Gilead Pharmaceuticals, Boston Scientific, Biosense Webster, and St. Jude Medical. Dr. Weiss is/has been a consultant (minor) to Biosense Webster and Stereotaxis. Dr. Crandall is/has been a consultant (minor) to Boston Scientific. Dr. Osborn is/has been a speaker and consultant (minor) to and has received honoraria from Medtronic, Boston Scientific, and St. Jude Medical.