Rhythm control in asymptomatic ‘early’ atrial fibrillation: birth of a new paradigm?

[academic.oup.com]

The strategy of initiating rhythm control soon after diagnosing AF (the authors introduce the term ‘early’ AF) was associated with a lower risk of the primary endpoint, a composite of death from cardiovascular causes, stroke, or hospitalization for heart failure or acute coronary syndrome, as compared with standard care over the following 5 years.



Edited 1 time(s). Last edit at 12/08/2021 03:56AM by susan.d.

When I first read the AFFIRM trial paper, in 2004 (mentioned in Susan's linked editorial), my thought was the analysis was bogus as the results were based on "intention to treat." Meaning, if you were in the rhythm control arm, your results were included there, even if you did not successfully maintain NSR.

For myself, I've been an advocate of rhythm control since the beginning (but not using chronic pharma). This started when I was in the middle of a 2 1/2 month episode that started about 2 months after my first afib episode. The EP said I was doing well out of rhythm and suggested I just stay there. I countered with a "Plan B" that I developed (and continue to tweak). Remarkably, the EP accepted and I've basically been successfully following that plan since.

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GeorgeN
When I first read the AFFIRM trial paper, in 2004 (mentioned in Susan's linked editorial), my thought was the analysis was bogus as the results were based on "intention to treat." Meaning, if you were in the rhythm control arm, your results were included there, even if you did not successfully maintain NSR.

For myself, I've been an advocate of rhythm control since the beginning (but not using chronic pharma). This started when I was in the middle of a 2 1/2 month episode that started about 2 months after my first afib episode. The EP said I was doing well out of rhythm and suggested I just stay there. I countered with a "Plan B" that I developed (and continue to tweak). Remarkably, the EP accepted and I've basically been successfully following that plan since.

I still struggle with this.. should I (at the age of 55) just stay here in afib. My rate is controlled. (with Cardizem). I can't really successfully take beta blockers. I've been in afib since July 7. Both my congenital cardiologist and EP think I should at least give ablation a try (having done all of Pharma except amniodorone which no one wants me on and I concur. I have had a dozen plus Cardioversions). IDK. My life is not very different from before in fact in some ways there is less stress. I sleep on my left side. I have the occasional glass of wine, I don't worry about my autistic son's meltdowns stressing me into afib .. same for exercise (which is a tad slower). I am concerned about the ablation making worse rhythms.. especially seeing all that Susan has gone thru. I don't know, do I have a question in here? if you have anything to offer up feel free. (My congenital stuff makes the ablation success percentage go down.. probably/maybe/ hard to tell.). I know you have posted potential negatives of staying here in afib. My reschedule (after my false alarm of a potential blood clot) should be in January but I have not bugged them to schedule it....



Edited 1 time(s). Last edit at 12/09/2021 12:30PM by bettylou4488.

The impression I've gained from my brief contact with 2 cardiologists and an E.D. doctor twice, recently, is that early rhythm control is regarded as the superior strategy now, compared to my experience with all sorts of types of doctors 3 years ago. The conclusion of this study points out that the data may not be relevant to those of us who were diagnosed with any sort of A-fib more than 4-6 weeks ago....

"However, at least two important questions remain to be resolved in order to implement this approach in clinical practice. (i) Are the benefits of early rhythm control limited only to ‘early’ AF (i.e. diagnosed within the previous 4–6 weeks) or can they be extrapolated to AF of longer duration? This is of utmost practical importance since most countries do not have the capacity to offer specialized care (including catheter ablation) to patients with incident AF within 4–6 weeks after initial diagnosis. (ii) Which feature of the proposed strategy of rhythm control is the decisive one: the systematic medical treatment, the early rhythm control, the systematic ablation if antiarrhythmic drugs fail, or all of them?"

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bettylou4488
I still struggle with this.. should I (at the age of 55) just stay here in afib. My rate is controlled. (with Cardizem). I can't really successfully take beta blockers. I've been in afib since July 7.

You're in persistent afib, which will be called longstanding persistent afib next July if you're still in afib. If you decide to just live with it, it will become known as permanent afib, and I know some perfectly happy permanent afibbers. They lead active lives (two of them are serious athletes), they're completely asymptomatic, they suffer no reduction in quality of life, and the data say they will live just as long as someone without afib. I would never recommend ablation to those people because you're right -- there's a chance you could turn asymptomatic afib into symptomatic afib or flutter. There are also the procedure risks, as small as they might be.

Going permanent is a valid option for people like you with minimal/no symptoms, adequate rate control, and the ability to be compliant with anticoagulants for life (or get an LAA occlusion device). If I could easily control my rate and had few/no symptoms, I doubt I would ever have pursued an ablation. But I was highly symptomatic, I find beta blockers almost worse than afib, and diltiazem is almost as bad. There was no scenario outside of ablation that would have restored my quality of life, so the choice was almost mandatory. But you do have the choice and I think you're right to consider "just living with it."

Just remember, you heard this from the "pro-ablation" guy.

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David_L
(i) Are the benefits of early rhythm control limited only to ‘early’ AF (i.e. diagnosed within the previous 4–6 weeks) or can they be extrapolated to AF of longer duration?

I think this has been answered in the last few years and the answer is yes, but it requires advanced training and a ton of experience. That EP at your local hospital with the impressive academic credentials? No, they probably can't restore your quality of life after being in longstanding persistent afib (LSPAF) for 5 years, but there are EPs who can (the longest I know of is 30 years). Doing so often requires isolating the LAA, and that's something most EPs aren't trained to do and won't do. But there's an entire conference dedicated to the subject of LAA isolation and it's attended by hundreds of EPs from around the world every years precisely because it offers the opportunity of finally being able to successfully ablate people suffering from LSPAF.

That said, it is true that this sort of care probably isn't available in many countries, and won't be offered by most public health services. You're almost certainly going to have to pay out-of-pocket if you want someone who can ablate your LSPAF in the UK and most of Europe, Australia, etc.

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Carey
(i) Are the benefits of early rhythm control limited only to ‘early’ AF (i.e. diagnosed within the previous 4–6 weeks) or can they be extrapolated to AF of longer duration?

I think this has been answered in the last few years and the answer is yes, but it requires advanced training and a ton of experience. That EP at your local hospital with the impressive academic credentials? No, they probably can't restore your quality of life after being in longstanding persistent afib (LSPAF) for 5 years, but there are EPs who can (the longest I know of is 30 years). Doing so often requires isolating the LAA, and that's something most EPs aren't trained to do and won't do.

I think it depends. For people who are in persistent afib, then the longer they are in afib, the harder\durable NSR is to restore (either with meds or ablation). For someone with relatively short, widely spaced paroxysmal episodes, then 4-6 weeks after diagnosis is not relevant. The issue with asymptomatic folks is they may be persistent for a long time before afib is discovered. In the 2000's here, we used to have discussions about the optimal time for an ablation, in the progression of the disease. Clearly that is before the afib becomes persistent. In Nov., 2012, I had afib 4 nights in a row. I was ready to dial Austin to get an ablation slot. I managed to turn my situation around and back to very widely spaced episodes. Had I not done that, I would have gotten a slot for an Natale ablation. I also am suspicious that my case would be complex because of my 2 1/2 month episode in 2004. Around 2010 or 11, there was a guy here with a similar long episode (months) during the initial stages of his afib. Then he had years of relative remission. Alas, his afib finally started to get worse. I recall he lived in the Boston area. A number of the local EP's he checked with said his case would be simple. He contacted the Bordeaux team. They said he'd be complex. He flew to Bordeaux and had his ablation there. Sure enough, he was a complex case. Hence my assumption I'd be complex also.

George, do you think simple cases may exist?
I was 57 when I got my very very first afib episode (14hrs long, self ending). I'm sure it was the very first one, for I was highly symptomatic. The second one, 10 days later, was diagnosed in the ER and followed by lots of controls showing I had a perfectly normal heart. No clots, so they performed an ECV.
The cardiologist prescribed propafenone, talked about ablation and suggested I see an EP.
BMI 20, normal to low BP, blood tests returned fine, good stress test. Bicyclist, but reasonably, normal heart chambers. No OSA and so on...
As neither propafenone, nor sotalol could improve things, it was easy to conclude I was a perfect candidate for ablation. And they figured it'd be easy.
It wasn't. I'm a complex case.
Had I known back then all I'm knowing now, I'd have said this EP: "I'm a complex case. Use your cryoballoon if you want, but check for other areas to ablate if necessary. And if you're not skilled enough to use a RF catheter efficiently, refer me to a highly experienced EP."
It appears now that what he did, he did correctly. But he did not enough. I don't know if what he did and did not made my case more complex, but I suspect it has little to see with that.
IMO, all cases have to be considered complex until appropriate and successful treatment has proven they weren't.