Procedure Beats Drugs for A-Fib With Heart Failure
For people with both atrial fibrillation and heart failure, a procedure called ablation can be life-saving, a new clinical trial shows.
Researchers found that when patients received the heart procedure, their risk of dying in the next few years was roughly half that of patients who took standard medications alone.
Experts said the findings, published Feb. 1 in the New England Journal of Medicine, should change the way many doctors treat the combined conditions.
Both heart failure and atrial fibrillation (a-fib) are common, each affecting several million Americans. And they often go hand-in-hand, said Dr. Mark Link, a heart arrhythmia specialist at the University of Texas Southwestern Medical Center, in Dallas.
Up to half of people newly diagnosed with heart failure have atrial fibrillation, he said.
Heart failure is a chronic condition in which the heart muscle is damaged -- by a heart attack or uncontrolled high blood pressure, for example -- and can no longer pump blood efficiently enough to meet the body's needs.
In atrial fibrillation, the heart's upper chambers quiver instead of beating effectively. It's not immediately life-threatening, but over time it can cause a stroke or lead to heart failure.
The question has been how best to treat people who have both atrial fibrillation and heart failure.
Atrial fibrillation can be treated with medications, including drugs that control the heart rate and "antiarrhythmic" drugs that keep the heart in its normal rhythm, Link said. The latter group includes medications like amiodarone and procainamide.
"The antiarrhythmic drugs work. They keep people in [normal] rhythm," said Link, who wrote an editorial published with the new study.
But the drugs also can do significant harm, he said. They can damage the lungs or liver, for example, or cause other types of heart rhythm problems.
And studies have found that when patients with heart failure and atrial fibrillation take antiarrhythmic drugs on top of other treatments, it doesn't improve their survival odds, said Dr. Nassir Marrouche, lead researcher on the new study.
In contrast, ablation can keep the heart in normal rhythm without the side effects of those drugs, explained Marrouche, a professor at University of Utah Health, in Salt Lake City.
And that, the new findings show, translates into a lower risk of death and hospitalization, he said.
During ablation, doctors use an energy source (usually radio waves) to create scar tissue in strategic locations on the heart. That disrupts the faulty electrical signals causing atrial fibrillation. The energy source is delivered through a catheter that is threaded through the blood vessels to the heart.
The new study included 363 patients who were randomly assigned to either take standard atrial fibrillation drugs or undergo ablation.
Over the next three years, 25 percent of patients in the drug group died. That compared with 13 percent of ablation patients.
People who had ablation were also less likely to land in the hospital due to heart failure: That happened to 21 percent, versus 36 percent in the medication group.
The trial was funded by the German medical device company Biotronik.
The ablation procedure, itself, does carry risks, Link said. Those risks include bleeding, infection and blood clots.
Of the 179 ablation patients in the trial, three had bleeding severe enough to require a transfusion. Another three had fluid buildup around the heart.
But, Link said, the lack of long-term risks is probably why ablation improves patients' survival, even though antiarrhythmic drugs typically do not.
To Link, ablation can be considered a first-line therapy for people with heart failure and atrial fibrillation -- bypassing antiarrhythmic drugs.
"Now you have a procedure with a proven mortality benefit and a hospitalization benefit," he said.
Link stressed that not everyone will be a candidate for ablation, but he said it is something patients can ask their doctor about.
Ablation has long been an option for atrial fibrillation -- so it is widely available, Marrouche said.
As with any procedure, it's best to have a doctor and hospital with a good amount of experience in ablation, Link noted.
The American Heart Association has more on ablation procedures.
SOURCES: Mark Link, M.D., professor of internal medicine, University of Texas Southwestern Medical Center, Dallas; Nassir Marrouche, M.D., professor of internal medicine and executive director, Comprehensive Arrhythmia Research and Management Center, University of Utah Health, Salt Lake City; Feb. 1, 2018, New England Journal of Medicine
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