Practice Update - ESC Congress 2017

Ablation of Atrial Fibrillation Improves Quality of

Life More than Drugs – CAPTAF Trial

Ablation of atrial fibrillation has been shown to improve quality of life more than drugs, even though the reduction

in atrial fibrillation burden did not differ significantly between treatments. This conclusion, based on results of the

multicenter, prospective, randomized Catheter Ablation compared with optimized Pharmacological Therapy for

Atrial Fibrillation (CAPTAF) trial, was presented at the 2017 European Society of Cardiology (ESC) Congress, from

August 26–30.

Dr. Carina Blomström-

Lundqvist

arina Blomström-Lundqvist, MD, PhD, of the

University of Uppsala, Sweden, explained

that previous randomized trials have reported

that pulmonary vein isolation is more effective in

preventing atrial fibrillation than antiarrhythmic

drugs. None of these trials, however, employed

continuous cardiac rhythm monitoring, so effects

on the burden of atrial fibrillation could not be

assessed reliably.

Until now, no trial of ablation of atrial fibrillation has

employed quality of life as the primary endpoint

even though the main indication for ablation of atrial

fibrillation is symptom relief. “Instead,” Dr. Blomström-

Lundqvist said, “30-s recurrences of atrial fibrillation

have been used as the primary endpoint, hardly a

relevant measure of successful therapy.”

The main purpose of the CAPTAF trial was to

compare the treatment effects of ablation of atrial

fibrillation and antiarrhythmic drugs using quality

of life as the primary endpoint and an implanta-

ble cardiac monitor to assess the burden of atrial

fibrillation.

CAPTAF included 155 patients with symptomatic

atrial fibrillation who had failed one drug for either

rate or rhythm control. Patients suffered at least

one episode of atrial fibrillation documented on

electrocardiography in the previous 12 months. At

least one symptomatic paroxysmal episode had

occurred in the previous 2 months, or at least two

symptomatic episodes of persistent atrial fibrilla-

tion necessitating cardioversion in the previous

12 months.

Patients received an implantable cardiac monitor

for a 2-month run-in period, then were randomized

to ablation with pulmonary vein isolation or anti-

arrhythmic drug therapy with adequate dosages

according to guidelines.

The primary endpoint was the change in general

health, as measured by the Short Form 36-item

health survey, from baseline to 12 months.

Secondary endpoints included quality of life

(by Short Form 36 and EuroQol 5 Dimensions),

symptoms, European Heart Rhythm Association

Symptom Classification, burden of atrial fibrillation,

and safety.

“We measured the burden of atrial fibrillation before

randomization so we got a good idea of burden at

baseline,” Dr. Blomström-Lundqvist said.

The main secondary endpoints were morbidity and

mortality as composite outcome, cardiovascular

hospitalization, symptoms, heart failure, left atrial

and ventricular function and diameters, exercise

capacity, health care economics, rhythm, atrial

fibrillation burden, successful vs failed treatment,

safety, and "cross-overs" over time.

“We tried to record silent atrial fibrillation via a

patient log book. We got a record for the first year

but in the second year, patients were reluctant to

record these episodes. We haven’t analyzed these

data yet.”

After 12 months of follow-up, the primary endpoint

of general health score had improved significantly

more in the ablation group (mean change 11.0;

95% confidence interval 6.7–15.2) than in the drug

group (mean change 3.1; 95% confidence interval

–0.9–7.1), P = .0084. Furthermore, all quality-of-life

Short Form 36 subscales except for bodily pain

and social functioning had improved significantly

more in the ablation group than in the drug group.

European Heart Rhythm Association symptom

score improved significantly more from baseline

to 12 months in the ablation group (from mean 3.0

± 0.7 to 1.6 ± 0.8) than in the drug group (from mean

2.9 ± 0.7 to 2.1 ± 1.1; P = .0079).

Reduction of burden in atrial fibrillation (that is, the

proportion of time in atrial fibrillation), obtained

from the implantable cardiac monitor, was numer-

ically larger in the ablation than in the drug group,

but change from baseline did not reach statistical

significance between treatment groups. The com-

plication rate was comparable between treatment

groups.

Dr. Blomström-Lundqvist concluded, “Quality of

life should be the primary endpoint in future tri-

als since the main indication for rhythm control is

improvement.”

She continued, “The lack of a statistically signifi-

cant difference between treatment groups in the

reduction in burden of atrial fibrillation suggests

that other mechanisms may explain the better

improvement of quality of life and symptoms

achieved with pulmonary vein isolation compared

to antiarrhythmic drugs.”

She added, “We confirmed that quality of life

improved greatly with ablation vs antiarrhythmic

drugs. We think it’s because of side effects of anti-

arrhythmic drugs, but we have not determined this

definitively.”

PracticeUpdate Editorial Team

ESC Congress 2017 • PRACTICEUPDATE CONFERENCE SERIES