Just saw this on my abstracts feed:
pubmed.ncbi.nlm.nih.gov/355...
A shame it has taken so long for such a comment to be published. The importance of rhythm control is so painfully obvious to so many of us, yet has still not fully reached front line practice. I hope this paper helps in recognising what I knew back in 1996 or so.
Not in any way a criticism of what the article says and in fact I agree in a very general sense, but the authors seem to be mostly ep's, so some bias. I guess the question is how early, say an ablation intervention is warranted and I think that really should be case by case.
When I walked into one ep department at a major teaching hospital, I saw the patient ablation power point presentation loaded on the computer BEFORE I had a chance to talk to the doctor. Guess what the recommendation was?
I should add that this is in the US where it's not uncommon for ep residents to drop in on all patients hospitilized for afib/cardioversion, etc, and basically do the ablation sell. If you want it, it usually can be done within weeks. I understand the protocols and wait times are a lot longer in the UK.
Jim
That's an interesting viewpoint. As you say, less likely to happen in a non-commercial health setting such as the NHS. But, what if ablation IS the answer? I knew early on, from reading and corresponding extensively, that I needed to get back to NSR before I remodelled too far, and had to push for an ablation (this was 2002 and PVIs were in their infancy and it was advisable to go to to someone already well-experienced, such as Haïssaguerre). I had a good 15 years on NSR until an AD upset the apple cart. That's my personal experience of ablation. I'd certainly agree with the paper's figure as to the limited success of AADs (p. 1935 bottom of col 2).
The other thing is that the lead author Prof Camm is not an EP. I know him personally as an ex patient and have a great deal of respect for him. The paper shows his steady hand on the tiller, imho.
What I hadn't appreciated is that rate control has been SO dominant - 89%, p. 1933 mid col 2). Some of this will arise from the general AF cohort bias towards the older patient, where AF is often less symptomatic (sometimes asymptomatic) and loss of CV fitness is less obvious. But for the younger patient, AF is often much more debilitating.
Where I think this paper, and indeed every paper on AF, needs to look at are (i) the age ranges of their cohorts and (ii) the tendency toward adrenergic vs. vagal triggers. This assessment is likely to show an age bias- vagal in younger and adrenergic in older. When papers don't recognise these differences, it's very hard to say that, for example, beta blockers do or don't improve a patient's QoL. BBs will make a vagal case worse, so when those figures are aggregated with adrenergic cases, the end result is invalid. But ablation suits both.
I agree with most of what you say. However, while the commercial interest is higher in the US, I'm not sure that is the only reason why ablation is not being offered so readily in the UK.
Seems that the criteria in the UK is different and arguably too far the other way, at least that's what it seems like reading here with people who should qualify for ablation after failing or not tolerating medical treatment, either not been given the go ahead or waiting too long for ablation.
So, yes, ablation often is the right answer, my point being case by case as opposed to what I have sometimes run into where here in the US it's offered to one and all with afib.
BTW I only was linked to the article's abstract. So maybe you can exerpt "the limited success of AAD's from p 1935).
Jim
Interesting to read this.
As an AF patient with 29 years experience with mainly persistent AF and far too many hospital admissions ( 22 dccvs + 4 ablations) I recall being told many times in the early days that rate control was the thing . Unfortunately ( or fortunately...) this could not be achieved in my case. The only drug working to any degree of success is Disopyramide.
I had an ablation and in no way felt that it was "sold" to me. Had a good discussion with the EP who suggested it, as my initial reaction was that I was not in favor of it. This was probably my 4th hospital admission for afib (in maybe 2 months) and the ablation was done about 2 days later. I've never had to wait weeks for anything important to be done, probably because of living in the US.
I found this very interesting. I have paroxysmal AF and am on an anti arrhythmic (amiodarone). I had episodes over the course of about four months but always self converted in about 2 to 4 hours before I started the amiodarone. Since then nothing and I’ve kept wondering to myself if it was possible that my AF would not get worse because it’s being controlled so effectively. Is it possible that effective rhythm control can remodel your heart out of AF, as it were?
Yes, I believe so. As I understand it, remodelling occurs in line with the errant electrical paths, so, normal NSR, normal cardiac muscle. The Amiodarone probably is preventing remodelling, as well as keeping you in NSR. Normal proviso: I am not a doctor!
Note that in the Abstract it says: "It [Rhythm control] has the potential to halt progression and potentially save patients from years of symptomatic AF; therefore, it should be offered more widely.". If the AF is asymptomatic, as I understand it, there is less justification for a rhythm-based approach. As has often been said here, ablation is more about Quality of Life than about Quantity of Life. I'm not sure this study changes that view, does it?
"Slave to the rhythm" - again!
Cardioversion - rhythm
Getting the Rhythm (the low down on AFib)
Informative article on "Atrial fibrillation: better symptom control with rate and rhythm management"
Rhythm Control (EAST- AF NET trial)
