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A Randomized Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Heart Failure
Open accessAbstract
Objectives This study sought to compare catheter ablation with rate control for persistent atrial fibrillation (AF) in heart failure (HF).Background The optimal therapy for AF in HF is unclear. Drug-based rhythm control has not proved clinically beneficial. Catheter ablation improves cardiac function in patients with HF, but impact on physiological performance has not been formally evaluated in a randomized trial.Methods In a randomized, open-label, blinded-endpoint clinical trial, adults with symptomatic HF, radionuclide left ventricular ejection fraction (EF) ≤35%, and persistent AF were assigned to undergo catheter ablation or rate control. Primary outcome was 12-month change in peak oxygen consumption. Secondary endpoints were quality of life, B-type natriuretic peptide, 6-min walk distance, and EF. Results were analyzed by intention-to-treat.Results Fifty-two patients (age 63 ± 9 years, EF 24 ± 8%) were randomized, 26 each to ablation and rate control. At 12 months, 88% of ablation patients maintained sinus rhythm (single-procedure success 68%). Under rate control, rate criteria were achieved in 96%. The primary endpoint, peak oxygen consumption, significantly increased in the ablation arm compared with rate control (difference +3.07 ml/kg/min, 95% confidence interval: 0.56 to 5.59, p = 0.018). The change was not evident at 3 months (+0.79 ml/kg/min, 95% confidence interval: -1.01 to 2.60, p = 0.38). Ablation improved Minnesota score (p = 0.019) and B-type natriuretic peptide (p = 0.045) and showed nonsignificant trends toward improved 6-min walk distance (p = 0.095) and EF (p = 0.055).Conclusions This first randomized trial of ablation versus rate control to focus on objective exercise performance in AF and HF shows significant benefit from ablation, a strategy that also improves symptoms and neurohormonal status. The effects develop over 12 months, consistent with progressive amelioration of the HF syndrome. (A Randomised Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Chronic Heart Failure; NCT00878384).
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“For patients who develop HFrEF as a result of rapid AF (tachycardiomyopathy), a rhythm control strategy is preferred, based on several relatively small patient cohorts and trials reporting improved LV function after restoration of sinus rhythm.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“Catheter ablation may be a useful method to restore LV function and quality of life in AF patients with HFrEF, 185,[226][227][228] but further data are needed.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“In such patients, catheter ablation is more effective than antiarrhythmic drug therapy.185,586,713,[717][718][719][720]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“Catheter ablation of AF is effective in restoring and maintaining sinus rhythm in patients with symptomatic paroxysmal, persistent, and probably long-standing persistent AF -in general as second-line treatment after failure of or intolerance to antiarrhythmic drug therapy.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“Fewer data are available reporting the effectiveness and safety of catheter ablation in patients with persistent or long-standing persistent AF, but all point to lower recurrence rates after catheter ablation compared to antiarrhythmic drug therapy with or without cardioversion.185,717,[723][724][725][726]1039”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“Fewer data are available reporting the effectiveness and safety of catheter ablation in patients with persistent or long-standing persistent AF, but all point to lower recurrence rates after catheter ablation compared to antiarrhythmic drug therapy with or without cardioversion.185,717,[723][724][725][726]1039”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
In the citing paper
“Several smaller trials suggest improved LV function after catheter ablation in HFrEF patients 185, 226-228, 778, 779”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [185]
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Citations
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Rhythm control versus rate control for atrial fibrillation and heart failure
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Sorted by citations
McDonagh, T. A., Metra, M., Adamo, M., Gardner, R. S., Baumbach, A., Böhm, M., Burri, H., Butler, J., Čelutkienė, J., Chioncel, O. D., et al. (2021) · PubMed · doi:10.1093/eurheartj/ehab670 · Cited by 20,604
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
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2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P. F., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castellà, M., Diener, H., Heidbüchel, H., Hendriks, J., et al. (2016) · EP Europace · doi:10.1093/europace/euw295 · Cited by 6,438
Metadata
- Authors
- Jones, D. G., Haldar, S. K., Hussain, W., Sharma, R., Francis, D. P., Rahman-Haley, S. L., McDonagh, T. A., Underwood, S. R., Markides, V., & Wong, T.
- Affiliations
- National Health Service (GB)
- Corresponding author
- Wong, Tom
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2013-05
- Volume
- 61
- Issue
- 18
- Pages
- 1894-1903
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2159999579
- Cited by
- 481
- References
- 44
- Citations by year
- 2026: 16 · 2025: 20 · 2024: 41 · 2023: 36 · 2022: 59 · 2021: 45 · 2020: 41 · 2019: 43 · 2018: 49 · 2017: 37 · 2016: 31 · 2015: 23 · 2014: 26 · 2013: 12
- FWCI
- 20.83
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- St. Jude Medical
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Keywords
- persistent atrial fibrillation, heart failure, catheter ablation, rate control, peak oxygen uptake, exercise capacity, left ventricular ejection fraction, brain natriuretic peptide, quality of life, 6-minute walk distance, sinus rhythm maintenance, cardiac rehabilitation, heart failure with reduced ejection fraction, heart failure with preserved ejection fraction
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, Atrial Fibrillation, Double-Blind Method, Electrocardiography, Female, Follow-Up Studies, Heart Conduction System, Heart Failure, Heart Rate, Humans, Male, Middle Aged, Prospective Studies, Quality of Life, Ventricular Function, Left, Treatment Outcome, Catheter Ablation, Young Adult
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