Elsevier

Heart Rhythm

Volume 10, Issue 9, September 2013, Pages 1257-1262
Heart Rhythm

Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long-term outcomes

https://doi.org/10.1016/j.hrthm.2013.05.013Get rights and content

Background

Many patients who develop atrial fibrillation (AF) will experience a worsening of their arrhythmia over time. The optimal time to proceed with catheter ablation during the disease course is unknown. Further, whether delays in treatment will negatively influence outcomes is unknown.

Objective

The purpose of this study was to examine the impact of delay in treatment after the first clinical diagnosis of AF on ablation-related outcomes.

Methods

A total of 4535 consecutive patients who underwent an AF ablation procedure that had long-term established care within an integrated health care system were evaluated. Recursive partitioning was used to determine categories associated with changes in risk from the time of first AF diagnosis to first AF ablation: 1: 30–180 (n = 1152), 2: 181–545 (n = 856), 3: 546–1825 (n = 1326), and 4: >1825 (n = 1201) days. Outcomes evaluated include 1-year AF recurrence, stroke, heart failure hospitalization, and death.

Results

With increasing time to treatment, surprisingly patients were older (1: 63.7 ± 11.1, 2: 62.6 ± 11.8, 3: 66.4 ± 10.2, 4: 67.6 ± 9.7; P <.0001) and had more hypertension (1: 53.0%, 2: 59.0%, 3: 53.8%, 4: 39.0%; P <.0001). For each strata of time increase, there was a direct increase of 1-year AF recurrence (1: 19.4%, 2: 23.4%, 3: 24.9%, 4: 24.0%: P trend = .02). After adjustment, clinically significant differences in risk of recurrent AF were found when compared to the 30–180 day time category: 181–545: odds ratio (OR) = 1.23, P = .08; 546–1825: OR = 1.27, P = .02; and >1825: OR = 1.25, P = .05. No differences were observed for 1-year stroke among the groups. Death (1: 2.1%, 2: 3.9%, 3: 5.7%, 4: 4.4%: P trend = .001) and heart failure hospitalization (1: 2.6%, 2: 4.1%, 3: 5.4%, 4: 4.4%; P trend = .009) rates at 1 year were higher in the most delayed groups.

Conclusion

Delays in treatment with catheter ablation impact procedural success rates independent of temporal changes to the AF subtype at ablation.

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.

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