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Radiofrequency Ablation as Initial Therapy in Paroxysmal Atrial Fibrillation
Open accessAbstract
BACKGROUND: There are limited data comparing radiofrequency catheter ablation with antiarrhythmic drug therapy as first-line treatment in patients with paroxysmal atrial fibrillation. METHODS: We randomly assigned 294 patients with paroxysmal atrial fibrillation and no history of antiarrhythmic drug use to an initial treatment strategy of either radiofrequency catheter ablation (146 patients) or therapy with class IC or class III antiarrhythmic agents (148 patients). Follow-up included 7-day Holter-monitor recording at 3, 6, 12, 18, and 24 months. Primary end points were the cumulative and per-visit burden of atrial fibrillation (i.e., percentage of time in atrial fibrillation on Holter-monitor recordings). Analyses were performed on an intention-to-treat basis. RESULTS: There was no significant difference between the ablation and drug-therapy groups in the cumulative burden of atrial fibrillation (90th percentile of arrhythmia burden, 13% and 19%, respectively; P=0.10) or the burden at 3, 6, 12, or 18 months. At 24 months, the burden of atrial fibrillation was significantly lower in the ablation group than in the drug-therapy group (90th percentile, 9% vs. 18%; P=0.007), and more patients in the ablation group were free from any atrial fibrillation (85% vs. 71%, P=0.004) and from symptomatic atrial fibrillation (93% vs. 84%, P=0.01). One death in the ablation group was due to a procedure-related stroke; there were three cases of cardiac tamponade in the ablation group. In the drug-therapy group, 54 patients (36%) underwent supplementary ablation. CONCLUSIONS: In comparing radiofrequency ablation with antiarrhythmic drug therapy as first-line treatment in patients with paroxysmal atrial fibrillation, we found no significant difference between the treatment groups in the cumulative burden of atrial fibrillation over a period of 2 years. (Funded by the Danish Heart Foundation and others; MANTRA-PAF ClinicalTrials.gov number, NCT00133211.).
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“Catheter ablation or combination therapy is often effective when antiarrhythmic drugs fail.226,[585][586][587]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
In the citing paper
“AF ablation, when performed in experienced centres by adequately trained teams, is more effective than antiarrhythmic drug therapy in maintaining sinus rhythm, and the complication rate, though not negligible, is similar to the complication rate for antiarrhythmic drugs.585,717,1042”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
In the citing paper
“AF ablation, when performed in experienced centres by adequately trained teams, is more effective than antiarrhythmic drug therapy in maintaining sinus rhythm, and the complication rate, though not negligible, is similar to the complication rate for antiarrhythmic drugs.585,717,1042”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
In the citing paper
“Complication rates were similar, but ablation was performed in expert centres, justifying catheter ablation as first-line therapy in selected patients with paroxysmal AF who ask for interventional therapy.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
In the citing paper
“As first-line treatment for paroxysmal AF, randomized trials showed only modestly improved rhythm outcome with catheter ablation compared to antiarrhythmic drug therapy.585,[721][722][723]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
In the citing paper
“Isthmus ablation is comparably safe and more effective than antiarrhythmic drug therapy, and is recommended for recurrent atrial flutter.[585][586][587]713”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [585]
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Translational Challenges in Atrial Fibrillation
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JCS/JHRS 2019 guideline on non‐pharmacotherapy of cardiac arrhythmias
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Catheter ablation in patients with persistent atrial fibrillation
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Atrial fibrillation burden: a new outcome predictor and therapeutic target
Becher, N., Metzner, A., Toennis, T., Kirchhof, P. F., & Schnabel, R. B. (2024) · European Heart Journal · doi:10.1093/eurheartj/ehae373 · Cited by 169
Rhythm control in atrial fibrillation
Piccini, J. P., & Fauchier, L. (2016) · The Lancet · doi:10.1016/s0140-6736(16)31277-6 · Cited by 147
Dretzke, J., Chuchu, N., Agarwal, R., Herd, C. P., Chua, W., Fabritz, L., Bayliss, S. E., Kotecha, D., Deeks, J. J., Kirchhof, P. F., et al. (2020) · EP Europace · doi:10.1093/europace/euaa041 · Cited by 146
“Atrial fibrillation ablation, mainly via pulmonary vein isolation, is an effective and safe intervention to restore and maintain sinus rhythm.(12,13) Recurrence of AF after catheter ablation is estimated to be between 20% and 45%.”
BackgroundSteinbeck, G., Sinner, M. F., Lutz, M., Müller‐Nurasyid, M., Kääb, S., & Reinecke, H. (2018) · European Heart Journal · doi:10.1093/eurheartj/ehy452 · Cited by 143
Kirchhof, P., Breithardt, G., Aliot, E., Al Khatib, S., Apostolakis, S., Auricchio, A., Bailleul, C., Bax, J., Benninger, G., Blomstrom-Lundqvist, C., et al. (2013) · Europace · doi:10.1093/europace/eut232 · Cited by 141
Kirchhof, P. F., BREITHARDT, G. E., Bax, J. J., Benninger, G., Blomström‐Lundqvist, C., Boriani, G., Brandes, A., Brown, H., Brueckmann, M., Calkins, H. G., et al. (2015) · EP Europace · doi:10.1093/europace/euv304 · Cited by 143
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Benefit of Pulmonary Vein Isolation Guided by Loss of Pace Capture on the Ablation Line
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JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias
Ono, K., Iwasaki, Y., Akao, M., Ikeda, T., Ishii, K., Inden, Y., Kusano, K., Kobayashi, Y., Koretsune, Y., Sasano, T., et al. (2022) · Circulation Journal · doi:10.1253/circj.cj-20-1212 · Cited by 132
Cryoballoon Ablation as Initial Treatment for Atrial Fibrillation
Andrade, J. G., Wazni, O. M., Kuniss, M., Hawkins, N. M., Deyell, M. W., Chierchia, G., Nissen, S. E., Verma, A., Wells, G. A., & Turgeon, R. D. (2021) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2021.06.038 · Cited by 127
Spotlight on the 2024 ESC/EACTS management of atrial fibrillation guidelines: 10 novel key aspects
Rienstra, M., Tzeis, S., Bunting, K. V., Caso, V., Crijns, H. J. G. M., De Potter, T. J. R., Sanders, P., Svennberg, E., Casado-Arroyo, R., Dwight, J., et al. (2024) · Europace · doi:10.1093/europace/euae298 · Cited by 128
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Catheter ablation of atrial fibrillation: an update
Haegeli, L., & Calkins, H. G. (2014) · European Heart Journal · doi:10.1093/eurheartj/ehu291 · Cited by 123
Duytschaever, M. F., Pooter, J. D., Demolder, A., Haddad, M. E., Phlips, T., Strisciuglio, T., Debonnaire, P., Wolf, M., Vandekerckhove, Y. R., Knecht, S., et al. (2019) · Heart Rhythm · doi:10.1016/j.hrthm.2019.11.004 · Cited by 121
Treatment of Atrial Fibrillation
Prystowsky, E. N., Padanilam, B. J., & Fogel, R. I. (2015) · JAMA · doi:10.1001/jama.2015.7505 · Cited by 117
Atrial Fibrillation Therapy Now and in the Future
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Dose-Escalation Study for Cardiac Radiosurgery in a Porcine Model
Blanck, O., Bode, F., Gebhard, M., Hunold, P., Brandt, S., Bruder, R., Großherr, M., Vonthein, R., Rades, D., & Dunst, J. (2014) · International Journal of Radiation Oncology*Biology*Physics · doi:10.1016/j.ijrobp.2014.02.036 · Cited by 111
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Rhythm Control in Heart Failure Patients With Atrial Fibrillation
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Walfridsson, H., Walfridsson, U., Nielsen, J. C., Johannessen, A. C., Raatikainen, P. M. J., Janzon, M., Levin, L., Aronsson, M., Hindricks, G., Kongstad, O., et al. (2015) · EP Europace · doi:10.1093/europace/euu342 · Cited by 90
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Association Between Sex and Treatment Outcomes of Atrial Fibrillation Ablation Versus Drug Therapy
Russo, A. M., Zeitler, E. P., Giczewska, A., Silverstein, A. P., Al‐Khalidi, H. R., Cha, Y., Monahan, K. H., Bahnson, T. D., Mark, D. B., Packer, D. L., et al. (2021) · Circulation · doi:10.1161/circulationaha.120.051558 · Cited by 85
Cabins, castles, and constant hearts: rhythm control therapy in patients with atrial fibrillation
Willems, S., Meyer, C. G., de Bono, J. P., Brandes, A., Eckardt, L., Elvan, A., Gelder, I. C. V., Goette, A., Gulizia, M. M., Haegeli, L., et al. (2019) · European Heart Journal · doi:10.1093/eurheartj/ehz782 · Cited by 80
“The long-term complication rates of antiarrhythmic drug therapy are comparable to complications in patients treated with AF ablation.(9,21) Although amiodarone has been associated with adverse outcomes in non-randomized analyses of patients at very high risk,(22) the safety of antiarrhythmic drug therapy found in rece…”
ResultThe Blinding Period Following Ablation Therapy for Atrial Fibrillation
Gottlieb, L. A., Dekker, L., & Coronel, R. (2021) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2021.01.011 · Cited by 80
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Efficacy and safety of ablation for people with non-paroxysmal atrial fibrillation
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Management of Atrial Fibrillation in Critically Ill Patients
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Metadata
- Authors
- Cosedis Nielsen, J., Johannessen, A., Raatikainen, P., Hindricks, G., Walfridsson, H., Kongstad, O., Pehrson, S., Englund, A., Hartikainen, J., Mortensen, L. S., & Hansen, P. S.
- Affiliations
- Gentofte Hospital (DK)
- Tampere University Hospital (FI)
- University Hospital Leipzig (DE)
- Linköping University Hospital (SE)
- Skåne University Hospital (SE)
- Rigshospitalet (DK)
- Örebro University Hospital (SE)
- Kuopio University Hospital (FI)
- Aarhus University Hospital (DK)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2012-10-25
- Volume
- 367
- Issue
- 17
- Pages
- 1587-1595
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2164489173
- Cited by
- 720
- References
- 26
- Citations by year
- 2026: 18 · 2025: 42 · 2024: 60 · 2023: 33 · 2022: 73 · 2021: 79 · 2020: 58 · 2019: 39 · 2018: 38 · 2017: 50 · 2016: 53 · 2015: 44 · 2014: 68 · 2013: 54 · 2012: 8
- FWCI
- 35.82
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Lund University Publications (Lund University) (submittedVersion, other-oa)
- Funders
- Sanofi
- Hjerteforeningen (05-4-B284-A466-22237)
- Foundation for Cardiovascular Research
- Sydäntutkimussäätiö
- St. Jude Medical
- Biosense Webster
- 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
- paroxysmal atrial fibrillation, radiofrequency catheter ablation, antiarrhythmic drugs, class Ic antiarrhythmic drugs, class III antiarrhythmic agents, first-line therapy, arrhythmia burden, symptomatic atrial fibrillation, cardiac tamponade
- MeSH terms
- Aged, Anti-Arrhythmia Agents, Atrial Fibrillation, Atrial Flutter, Female, Flecainide, Follow-Up Studies, Humans, Male, Middle Aged, Propafenone, Quality of Life, Electrocardiography, Ambulatory, Treatment Outcome, Catheter Ablation, Cost of Illness, Statistics, Nonparametric, Intention to Treat Analysis
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