PracticeUpdate Cardiology March 2019

EDITOR’S PICKS 13

Impact of Atrial FibrillationAblation on Recurrent Hospitalization JACC: Clinical Electrophysiology Take-home message • In this prospective study of patients with atrial fibrillation undergoing ablation procedures (n=2720), the authors evaluated the association between ablation and hospitalization and antiarrhythmic drug use, determining that ablation was associated with reduced antiarrhythmic hospitalization. Total cardiovascular hospitalization rates were also lower. These reductions in hospitalizations were most pronounced in younger patients and those with sleep apnea. • The authors concluded that ablation for atrial fibrillation reduces cardiovascular hospitalizations within the first year after ablation by specifically reducing hospital- izations for atrial fibrillation and heart failure. Abstract

before ablation to 1,034 hospitalizations in the year after ablation, which was driven primarily by a 56% reduction in arrhythmic hospitalization. Nonarrhyth- mic cardiovascular hospitalizations also declined through a 43% drop off in HF hospitalizations. Noncardiovascular hospitalization rates did not significantly change. Age younger than 55 years (odds ratio [OR]: 1.43; p < 0.001), obstructive sleep apnea (OR: 1.38; p < 0.001), and HF (OR: 1.29; p = 0.024) were multivariate predictors for decreased arrhythmic hospitalization. Rates of antiarrhythmic drug use also significantly declined post-procedure by 37.5% (p < 0.001). CONCLUSIONS In this nationwide cohort, AF abla- tion was associated with significant decreases in arrhythmic and nonarrhythmic cardiovascular hospitalizations, which was driven by reductions in hospitalization for AF and HF. Impact of Atrial Fibrillation Ablation on Recurrent Hospitalization: ANationwide Cohort Study. JACC Clin Electrophysiol 2018 Dec 26;[EPub Ahead of Print], J Guo, HM Nayak, SA Besser, et al. www.practiceupdate.com/c/78045 to reductions in need for treatment of arrhythmias and heart failure. There was also a decrease in antiarrhythmic drug use. Age younger than 55 years, history of obstructive sleep apnea, and history of heart failure were multivariate predictors of reduced antiarrhythmic hospitalizations. These findings suggest that AF ablation favorably reduces recurrent hospitaliza- tions in the community setting by reducing the risk of AF and its sequelae. AF ablation has not reached “steady state” because improvements in equipment, techniques and patient selection are still evolving. Nevertheless, the outcomes from this study are encouraging for patients with the most prevalent arrhythmia in the United States, affecting about 6million and costing between an estimated $6 and $26 billion, annually.

OBJECTIVES This study assessed the impact of atrial fibrillation (AF) ablation on hospitalization and anti- arrhythmic drug use in the community setting. BACKGROUND Despite the widespread increase in the use of catheter ablation to treat AF in the United States, the impact of ablation on arrhyth- mic, cardiovascular, and noncardiovascular hospitalizations remains unclear. METHODS The national prospectively acquired Truven Health MarketScan data set (January 1, 2008 to December 31, 2014) was used to iden- tify patients who underwent first time AF ablation with uninterrupted enrollment for 24 months (12 months pre-ablation and 12 months post-abla- tion). Multivariate logistic regression was used to determine predictors of hospitalization. RESULTS Of 5,238 patients who underwent AF ablation for the first time, 2,720 patients with unin- terrupted enrollment were analyzed (age 60 ± 10 years; 29% were women, 79% had hypertension, and 23% had heart failure [HF]). AF ablation was associatedwith significantly reduced all-cause hos- pitalization from 1,669 hospitalizations in the year COMMENT By Douglas P. Zipes MD C atheter ablation of atrial fibrillation (AF) has provided a fundamen- tal change in treatment options for AF patients. However, reported efficacy results on establishing and maintaining sinus rhythm and on arrhythmic, car- diovascular, and non-cardiovascular hospitalizations have varied signifi- cantly according to EP skill set, ablation methods, and type (duration) of AF. The present study used a national, prospec- tively acquired dataset to analyze 2720 patients with 24 months of uninterrupted enrollment in a community setting. The authors found that AF ablation reduced overall hospitalization rates, in particular, reductions in arrhythmic and non-arrhythmic cardiovascular hospi- talizations, but not non-cardiovascular hospitalizations. Outcomes were due

CONCLUSIONS AND RELEVANCE Among ambu- latory adults with hypertension, treating to a systolic blood pressure goal of less than 120 mm Hg compared with a goal of less than 140 mm Hg did not result in a significant reduction in the risk of probable dementia. Because of early study termination and fewer than expected cases of dementia, the study may have been underpowered for this end point. Effect of Intensive vs Standard Blood Pres- sure Control on Probable Dementia: A Randomized Clinical Trial. JAMA 2019 Jan 28;[EPub Ahead of Print], JD Williamson, NM Pajewski, AP Auchus, et al. www.practiceupdate.com/c/79189 Moreover, concerns over falls pale against the clinical benefits noted, and clear benefits have been noted even in the very old population (ie, >75 years). Hypertension is nearly ubiquitous in the US adult population and contributes sub- stantially to the burden of cardiovascular disease; we now know a better way to treat hypertension (more research and better therapeutics are still needed), what goals to target and in whom, and now with some certainty of reasonable safety and preservation of cognitive function. As a collective, we should now consider these newly published data and target the ideal evidence-based, guideline-driven treatment of hypertension in appropri- ate patients as safe, effective, and one of today’s clinical imperatives.

VOL. 4 • NO. 1 • 2019