First-line ablation limits progression to persistent AF

Fewer patients with atrial fibrillation (AF) progressed to persistent (AF) when receiving first-line ablation compared with first-line antiarrhythmic drug therapy, data from the PROGRESSIVE-AF trial showed. Secondary outcomes confirmed the superiority of first-line ablation in the young, relatively healthy study population.

“AF is a chronic and progressive condition and persistent AF is linked to adverse clinical events, such as stroke, heart failure, and death” explained Dr Jason Andrade (University of Montreal, Canada). “Since catheter ablation modifies the pathogenic mechanism of AF, early initiation of this procedure may lead to improved clinical outcomes.”

The PROGRESSIVE-AF trial (NCT05514860) randomised 303 patients with AF (mean age 58 years) 1:1 to first-line catheter ablation or first-line antiarrhythmic drugs. The primary endpoint was the time-to-first occurrence of an episode of persistent atrial tachyarrhythmia [1].

At 3 years, the incidence of persistent AF was reduced by 75% in the ablation compared with the antiarrhythmic drug group (HR 0.25, 95% CI 0.09–0.70). The observed effect was consistent across subcomponents of the primary outcome, namely atrial tachyarrhythmias lasting more than 7 days (HR 0.30; 95% CI 0.10–0.93) and cardioversion for atrial tachyarrhythmia lasting between 2 and 7 days (HR 0.14; 95% CI 0.02–0.85). Furthermore, 42.7% of the patients in the ablation arm were free of any recurrence of atrial tachyarrhythmia after 3 years compared with 9.3% in the antiarrhythmic drug arm (HR 0.49; 95% CI 0.37–0.65). Quality of life after 3 years of follow-up was also significantly better in patients randomised to the ablation arm. The Atrial Fibrillation Effect on Quality-of-Life (AFEQT) revealed mean differences from baseline of 28.1 versus 24.8 respectively, while the mean difference from baseline of EQ-5D-assessed quality of life was 0.06 versus 0.01 and the relative risk for symptoms of AF was 4.8% versus 17.1% respectively (all comparisons ablation vs antiarrhythmic drug). At 3 years, fewer adverse events were reported in the ablation group (11.0%) than in the antiarrhythmic drug group (23.5%; RR 0.47; 95% CI 0.28–0.79). Also, serious AEs were numerically less frequently observed in the ablation arm (4.5% vs 10.1%; RR 0.45; 95% CI 0.19–1.05).

Dr Andrade concluded that first-line treatment with ablation led to a lower risk of progression to persistent AF than first-line treatment with antiarrhythmic drug therapy. Dr Carina Blomström Lundqvist agreed that first-line ablation reduces AF progression compared with initial antiarrhythmic drug therapy, but that the optimal patient and timing remain unclear: “The CLOSE-to-CURE study (NCT02925624) demonstrated that patients respond very well to ablation, even if they are in a progressed stage of the condition and have a high AF burden” [2].

1. 
   
   1. Andrade JG, et al. The impact of “first-line” rhythm therapy on atrial fibrillation progression: the PROGRESSIVE-AF trial. LBS.08, AHA Scientific Sessions 2022, 05–07 November, Chicago, USA.
   2. Strisciuglio T, et al. EP Europace. 2020;22(8):1189–1196.

 

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Posted on 11 January 2023