Practice Update: Cardiology

ESC 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.

his conclusion, based on results of

the multicenter, prospective, rand-

omized Catheter Ablation compared

with optimized Pharmacological Therapy

for Atrial Fibrillation (CAPTAF) trial, was pre-

sented at the 2017 European Society of

Cardiology (ESC) Congress, from August

26–30.

Carina Blomström-Lundqvist, MD, PhD,

of the University of Uppsala, Sweden,

explained that previous randomized trials

have reported that pulmonary vein isola-

tion is more effective in preventing atrial

fibrillation than antiarrhythmic drugs. None

of these trials, however, employed contin-

uous cardiac rhythm monitoring, so effects

on the burden of atrial fibrillation could not

be assessed reliably.

Until now, no trial of ablation of atrial fibril-

lation has employed quality of life as the

primary endpoint even though the main

indication for ablation of atrial fibrillation

is symptom relief. “Instead,” Dr. Blom-

ström-Lundqvist said, “30-s recurrences

of atrial fibrillation have been used as the

primary endpoint, hardly a relevant meas-

ure of successful therapy.”

The main purpose of the CAPTAF trial was

to compare the treatment effects of abla-

tion of atrial fibrillation and antiarrhythmic

drugs using quality of life as the primary

endpoint and an implantable cardiac moni-

tor to assess the burden of atrial fibrillation.

CAPTAF included 155 patients with symp-

tomatic atrial fibrillation who had failed

one drug for either rate or rhythm control.

Patients suffered at least one episode of

atrial fibrillation documented on electro-

cardiography 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 fibrillation 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 pulmo-

nary vein isolation or antiarrhythmic 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 base-

line 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 fibril-

lation before randomization so we got a

good idea of burden at baseline,” Dr. Blom-

ström-Lundqvist said.

The main secondary endpoints were mor-

bidity and mortality as composite outcome,

cardiovascular hospitalization, symptoms,

heart failure, left atrial and ventricular func-

tion and diameters, exercise capacity, health

care economics, rhythm, atrial fibrillation bur-

den, 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 qual-

ity-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 symp-

tom 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 fibrilla-

tion), obtained from the implantable cardiac

monitor, was numerically larger in the abla-

tion than in the drug group, but change

from baseline did not reach statistical

significance between treatment groups.

The complication rate was comparable

between treatment groups.

Dr. Blomström-Lundqvist concluded, “Qual-

ity of life should be the primary endpoint

in future trials since the main indication for

rhythm control is improvement.”

She continued, “The lack of a statistically

significant 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 anti-

arrhythmic drugs.”

She added, “We confirmed that quality of

life improved greatly with ablation vs anti-

arrhythmic drugs. We think it’s because of

side effects of antiarrhythmic drugs, but we

have not determined this definitively.”

PracticeUpdate Editorial Team

ESC 2017

VOL. 2 • NO. 2 • 2017