Initial cryoballoon ablation better than antiarrhythmic drugs for lowering risk of AF progression

According to the results from the PROGRESSIVE-AF study, produced in the New England Journal of Medicine, initial treatment of paroxysmal AF with cryoballoon ablation lowered the incidence of AF progression by 75% at three years versus antiarrhythmic drugs. The findings were also presented at the 2022 Scientific Sessions of the American Heart Association.

Atrial fibrillation is a progressive, chronic disorder, and persistent atrial fibrillation forms are associated with increased risks of heart failure and thromboembolism. Catheter ablation as initial treatment may modify the pathogenic mechanism of AF and change the progression to persistent atrial fibrillation.

Jason G. Andrade, the Centre for Cardiovascular Innovation, Vancouver, BC, Canada, and colleagues reported the 3-year follow-up results of patients with paroxysmal, untreated atrial fibrillation. The patients (n=303) were the enrollees of a trial in which they were randomly allocated to undergo initial rhythm-control treatment with cryoballoon ablation (n=154) or to receive antiarrhythmic drug therapy (n=149).

Implantable loop recorders were placed at the time of trial entry in all the patients and were evaluated by downloading daily recordings and in-person visits every six months. The researchers then collected data on the first episode of persistent atrial fibrillation; lasting for ≥7 days or lasting 48 hours to 7 days but needing cardioversion for termination, recurrent atrial tachyarrhythmia; defined as flutter, atrial fibrillation, or tachycardia lasting ≥30 seconds, the burden of atria fibrillation calculated as the percentage of time in AF, health care utilization, safety, and quality-of-life metrics.

The study demonstrated the following findings:

• Over 36 months of follow-up, in the ablation group, 1.9% of patients had an episode of persistent atrial fibrillation, compared with 7.4% of patients in the antiarrhythmic drug group (hazard ratio, 0.25).
• Recurrent atrial tachyarrhythmia occurred in 56.5% of patients in the ablation group and 77.2% in the antiarrhythmic drug group (hazard ratio, 0.51).
• The median percentage of time in atrial fibrillation (burden of AF) was 0.00% in the ablation group and 0.24% in the antiarrhythmic drug group.
• At three years, 5.2% of patients in the ablation group and 16.8% of patients in the antiarrhythmic drug group had been hospitalized (relative risk, 0.31).
• Serious adverse events occurred in 4.5% of patients in the ablation group and 10.1% in the antiarrhythmic drug group.

"Initial treatment of atrial fibrillation with cryoballoon ablation is tied to a lower incidence of recurrent atrial tachyarrhythmia or persistent atrial fibrillation over a follow-up of 3 years compared to the initial use of antiarrhythmic drugs," the researchers wrote.

Reference:

Andrade JG, et al. LBS.08. Treating atrial and supraventricular arrhythmias Presented at American Heart Association Scientific Sessions; Nov. 5-7, 2022; Chicago (hybrid meeting).