Ablation vs. Antiarrhythmic Drugs for Paroxysmal AF

"Radiofrequency Ablation and Antiarrhythmic Drugs Fight to
a Tie."

In patients with paroxysmal AF, initial strategies of ablation and AADs led to similar outcomes.
Radiofrequency ablation is moderately effective in the treatment of drug-refractory atrial fibrillation (AF; JW Cardiol Feb 3 2010 (Link to: [cardiology.jwatch.org]) ). However, its effectiveness as a first-line therapy is unclear. In a multicenter, partially industry-supported trial, investigators randomized 294 patients with paroxysmal AF (defined as episodes <7 days in duration) to treatment with ablation or an antiarrhythmic drug (AAD). All patients were aged 70 or younger; other exclusion criteria included prior ablation or AAD use, left atrial diameter >50 mm, and left ventricular ejection fraction <40%.
Ablation operators used standard pulmonary vein isolation techniques guided by three-dimensional mapping systems. AADs were predominantly class IC agents. Patients in the ablation group underwent a mean of 1.6 procedures; in the AAD group, 36% of patients ultimately underwent ablation. The primary endpoints — cumulative and per-visit AF burdens on 7-day Holter monitoring at 3-month intervals up to 24 months — did not differ significantly between the two groups, except at 24 months, when the burden was significantly lower in the ablation group. Symptom reduction at 24 months and improvement in physical well-being over time were better in the ablation group than in the AAD group. Serious adverse events did not differ significantly between the groups but included one procedure-related death in the ablation group.
Radiofrequency Ablation and Antiarrhythmic Drugs Fight to a T... [cardiology.jwatch.org]...
Comment: In this study, 2-year outcomes of initial ablation were roughly equivalent to those of antiarrhythmic drug treatment in patients who were optimal candidates for ablation. Importantly, because the cohort was highly selected, these results cannot be extrapolated to older patients or those with heart failure, left ventricular ejection fraction <40%, large left atrium, or persistent or chronic atrial fibrillation. As an editorialist notes, patient characteristics and the complications associated with ablation must be carefully considered when assessing treatment risks and benefits.
— Mark S. Link, MD (Link to: [cardiology.jwatch.org] /misc/board_about.dtl#aLink)
Published in Journal Watch Cardiology (Link to: [cardiology.jwatch.org]) October 24, 2012
Citation(s):
Nielsen JC et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 2012 Oct 25; 367:1587. (http://dx.doi.org /10.1056/NEJMoa1113566 (Link to: [dx.doi.org] /NEJMoa1113566) )
Stevenson WG and Albert CM. Catheter ablation for paroxysmal atrial fibrillation. N Engl J Med 2012 Oct 25; 367:1648. (http://dx.doi.org /10.1056/NEJMe1210548 (Link to: [dx.doi.org] /NEJMe1210548) )

I guess you have to join to read those links. All I was really interested in was what the actual numbers were for this?


The primary endpoints — cumulative and per-visit AF burdens on 7-day Holter monitoring at 3-month intervals up to 24 months

See link at NEJM. Summary numbers are shown. Ablation is still way better in terms of AF burden and hospital admissions if I read it right.

[www.nejm.org]

How about some statistics for PAF cure from quitting SAD eating habits?? -- like that study could ever happen . . . . .

Erling, 84, full-time NSR, ~11 years free of PAF by nutrition only: [www.afibbers.org]



Edited 2 time(s). Last edit at 10/31/2012 04:29PM by Erling.

Why is it that you are free from AF when others have tried your protocol, not eating processed foods, cooking from scratch and also on a similar vitamin regime, yet they still had AF and finally opted for an ablation.

I believe there just has to be more than a sound diet/suppements, something else is play.

Liz

I thought I had it fixed with Iodine for a while. Just one noticeable episode in 6 mths (of course there could have been some silent self terminating ones at night, possibly) . But then it came back with a vengeance. I guess everyone is different and some have a situation where it can be controlled by diet or supplementation alone.

Hi Liz,

Its always a good idea to give a good try at the diet and supplement approach not just as a temporary trial, but as life style modifications for a healthier life.

But you are also very right Liz, that it is not by any means a promised or even likely panacea either for everyone, or perhaps not even a majority. Considering the majority of people really going to the lengths that many of us have, including Erling, while admirable, is not that often going to realistically happen within a larger population. It can be tough for many to keep at it and stay focused and stay on top of developing nutritional science and insights.

Also, even issues like spouse or significant others compliance or acceptance of what they will often view as a radical and frustrating diet/protocol that may impact their lifestyle as well, such that they might feel it intrudes too much on their relationship can thus also become a barrier to following through with the one-pointed dedication that it can require to keep the beast at bay by this method alone.

In addition, every EP in the world can recount a small, but significant number of his/her patients that have full blown paroxysmal AFIB for a good period of time, even years, and then suddenly it stops and disappears for no apparent reason and either never comes back or at least not for a very long time.

That being so, it implies that in any group of people its possible that any one or more who reports apparent success no matter what protocol they are pursuing at the moment could well be just part of that lucky cohort of people who had a 'spontaneous remission' so to speak that perhaps was encouraged to some degree by the new dietary changes or the new drug or new supplements (or maybe it was mostly coincidental?). However, one has to acknowledge that any given diet or protocol may not have necessarily been the sole deciding factor it might be getting credit for, simply from the synchronicity of adding the diet/supplement/drug during the same general time frame of the onset of such a remission.

I'm not at all suggesting that such a scenarios explains Erling's or anyone else's long term success and I feel strongly that the nutritional discipline and knowledge of what should help is a big contributing factor in most cases. But with the very small samples that we know of here at least, of those who have carved out very long term success with nutritional factors alone, and then combined with this well known pattern of a small but steady number of afibber's who suddenly or gradually seem to 'grow out of it' then adds this other factor into the possible equation.

In all fairness, anyone reporting a success story of only one .. or even just of a modest few in number of successes ... cant themselves be 100% sure they are not just among the genetically lucky who got one of these big lottery breaks at the right time and that their AFIB possibly went quiet as much, or even more, in spite of whatever they were doing rather than necessarily as a direct cause and effect result of their experiments with nutrition??

Any honest scientific approach has to acknowledge that possibility when the sample size of total success for a decade is so relatively small. At least until we can do real solid long term blinded studies or meta-anaylsis that shows a direct cause and effect result in eliminating AFIB which has been going on for a while.

However, that in no way undermines the wisdom in adopting such a diet and supplements that likely will very much help the cause, and in some cases may be all that is needed! And I feel in almost every case such a choice would result in a healthier overall body than sticking with a nutrient sparce typical American diet, regardless of your AFIB status.

Its also possible for some people, particular as one gets older, to enter a long sustained period of truly silent AFIB episodes either paroxysmal, and even more commonly as persistent AFIB, when it can become truly asymptomatic. Or one's AFIB might shift to only happening as shorter night time breakthroughs for the most part and without a pacemaker or on board EKG, they might truly be unaware of any periodic breakthroughs they might be having.

There is also the issue of proper nutrient absorption and assimilation that varies greatly in people and tends to increasingly get worse on average with advancing age which can mean you don't get the real world possible benefit for your AFIB even though you have been religious in following the protocols? Also, like in all things biologic, there are exceptions to every rule and some people just have lucky genetics that may predispose them to a greater likelihood of success from these very interesting and worthwhile nutritional additions to one's life, but which might not translate nearly as well as a 'cure' within the general population', as an ideal theory might suggest.

Again,I strongly support learning about and adopting to whatever degree is comfortable and workable for you and your family the best nutritional and supplemental habits you can muster. But I also suggest not making it only about stopping AFIB to be the deciding factor for whether or not to go this route or to continue it if AFIB continues, but to look at it as a positive change for strengthening your overall health rather than judging your nutritional protocol a failure if you still require an ablation to put this very complex and stubborn genie back in the bottle.

My feeling is, you use every asset at your disposal that you can, and not get too cocky about 'cures' regardless of the method or procedure that has helped quiet things down. AFIB is a great humbler and just when we are sure we have it totally licked the relentless process of aging combined with any number of variables we cannot predict can pop that balloon again and put is right back in the 'dealing with it again' mode to one degree or another.

My view is to just be grateful for every day of NSR we have and try to enjoy life to the fullest and to roll with the punches whenever and from wherever they arise as best we can.

Shannon



Edited 1 time(s). Last edit at 10/25/2012 06:59PM by Shannon.

Thank you Shannon for your very insightful posting.

Actually, we do have some data regarding the likelihood of measures other than ablation and surgical procedures being successful in managing afib.

The findings and conclusions of LAF Survey 14 [www.afibbers.org] are based on the responses from 224 afibbers who had attempted to reduce or eliminate their afib burden through means other than ablation or surgical procedures, and who had been on their program for at least 6 months. More than half the respondents believed they had found a way to materially reduce or completely eliminate their afib episodes. The successful protocols used to eliminate afib were evenly split between the use of pharmaceutical drugs and the use of alternative approaches such as trigger avoidance, supplementation, dietary changes, stress management, and elimination of underlying conditions such as GERD (gastroesophageal reflux disease), sleep apnea and hypoglycemia. NOTE: Success in managing afib was defined as a 50% reduction in afib burden over the most recent 6-month period as compared to a 6-month period prior to starting on the protocol that ultimately proved successful.

The survey revealed that vagal afibbers were significantly more likely to be successful than were mixed afibbers and that afib burden prior to the intervention did not affect the outcome of the intervention. Other significant findings were:

• The most popular intervention program was trigger avoidance engaged in by 88% of all respondents. This was followed by supplementation (84%), therapy with pharmaceutical drugs (79%), dietary changes (55%), and other therapies (55%).

• Avoidance of caffeine had been found useful by 67% of respondents, alcohol avoidance by 56%, and avoidance of aspartame and MSG by 38% and 34% respectively.

• The most important dietary changes were elimination of wheat, gluten and dairy products, and a switch to the Paleo diet. These changes were significantly more successful among females and vagal afibbers.

• Eighty-five percent of responders had tried supplementation. The most effective supplement was magnesium glycinate, which had been found beneficial by 48% of those who had tried it. Potassium supplementation (including low-sodium V8 juice) had been tried by 79% of all respondents and found beneficial by 43%. Taurine had been tried by 43% and found beneficial by 32%. About half of those supplementing with magnesium also took potassium and taurine.

• A comparison between 46 afibbers (Group A) who had managed to completely eliminate their afib episodes over the most recent 6 months and 40 afibbers [Group B] whose condition had worsened or remained constant revealed the following:

- The median birth weight in Group A was substantially lower than in Group B.
- There was no indication that members of Group B had tried fewer interventions than had members in Group A.
- Group B had achieved no improvement at all through dietary changes, while Group A had achieved significant benefits, especially by changing to the Paleo diet (75%), avoiding dairy (60%), and eliminating wheat and gluten (33%).
- Group A had achieved very significant benefits from supplementing with magnesium, potassium and taurine, while Group B had seen little or no benefit from supplementing.

Overall, it would appear that Groups A and B and indeed, YES and NO responders, are markedly different in that practically nothing worked for NO responders and those in Group B, while several different protocols worked quite well for YES responders and those in Group A.

It is not apparent what the difference is since there is no indication that NO responders were less diligent in their approach than were YES responders. It is possible that the statistically significant lower birth weight in Group A could contain a clue, but it is certainly not obvious what that clue might be, especially since a higher birth weight is generally associated with better cardiovascular health.

I discussed the birth weight finding with Pat Chambers, MD and he pointed out that a higher birth weight such as found in Group B is associated with increased baroreflex sensitivity[1] and that an increased baroreflex sensitivity, in turn, is associated with more difficulty in dealing with sudden changes in autonomic tone that could lead to an afib episode. Thus, it may well be that lone afibbers can be divided into two groups - those (like in Group A) whose main underlying problems are magnesium deficiency, wheat sensitivity, etc. and those (like in Group whose main underlying problem is an increased baroreflex sensitivity. Clearly, it would be much easier to correct a magnesium deficiency than an increased baroreflex sensitivity, perhaps explaining why "nothing worked" for Group B. It is also intriguing to speculate that the reason why mixed type afibbers (neither pure adrenergic nor pure vagal) have a more difficult time reducing their afib burden could be that they have increased baroreflex sensitivity. Hopefully, medical researchers will some day cast more light over this finding.

[1] Leotta, G, et al. Effects of birth weight on spontaneous baroreflex sensitivity in adult life. Nutrition, Metabolism and Cardiovascular Diseases, Vol. 17, May 2007, pp. 303-10

There is obviously not much we can do about our birth weight or inherited afib. The idea, that we should all be able to manage our afib by “natural” means if we are just diligent enough, is simply not realistic in the real world.

Hans

Many words, no science. Statistics and correlations, though useful, are not science. Lest I muddy Mike's topic further I'll quit by asking:

Mike Harris, as a fellow engineer/ scientist, what is your take on the statistics in the article you offered?

Erling, 10 years increasing Mg deficiency/ Ca excess/ Fluoridated water/ SAD diet = atrial fibrosis + low cell voltage --> 7 years PAF/AFl --> 10+ years freedom by use of God given brain power, not by "good genes".



Edited 1 time(s). Last edit at 10/25/2012 11:38PM by Erling.

Erling,

Reading your well-written success story has inspired me to want to take a serious stab at dietary improvement and supplementation. I hadn't even yet tried taurine before going on Flecainide, yet I have read several sources saying it can be deficient in people with AFib. And your work at balancing Omega 6's and 3's sounds inspiring. You didn't just blindly adopt the Paleo diet (which sounds extreme to me, as wheat and dairy are some of my favorite foods) but it sounds like you took the approach at balancing your fats and avoiding processed foods and also increasing your nutrition.

At this point, for me to improve my diet and try taurine, at some point I'll need to get weaned off Flecainide (and, of course Metoprolol, which was possibly aggravating my AFib before I went on AFib). And I'd want to work with a sympathetic cardiologist on this, not just do it on my own. I think the best plan would be to clean up my diet and try additional supplements for a month or two then start the process of weaning myself off Flecainide, which would tell me if the program were working.

Of course, as one person mentioned, maybe you would have improved anyways (spontaneous remission) without your dietary changes, but then again, maybe they helped, and maybe spontaneous remission could happen to me. And maybe cleaning up my diet can help with that.

Diane

Diane - By process of elimination and adjusting various food intakes, you may learn that some of your favorites cause a systemic reaction.
Wheat, gluten and dairy are notorious for causing food sensitivitiy reactions which result in systemic (silent) inflammation. That's a definite contributor to vagal irritation. You can be tested for the secretory immunoglobulins that are considered 'markers' for these sensitivities.
Not everyone will be sensitive nor will sensitive people have overt symptoms.

Read more here as just one example of many regarding silent inflammation affects
[www.cyrexlabs.com]

Jackie

Erling,
I share your dubiousity (is there such a word) with regard to the tentative statistics andcorrelations presented in this report, having long subscribed to the old saw that "figures don't lie, but liars sure figure." Actually, my intent in passing along such findings are oriented more toward stimulating a conversation, rather than advocating for any particular point of view, and that is certainly the case here.

Mike

Diane,

If your afib episodes are vagally mediated metoprolol will significantly worsen your situation.

Hans

More analysis and commentary on the results at heartwire.

[www.theheart.org]