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Journal Club 27 August 2014

Paper


Radiofrequency Ablation vs Antiarrhythmic Drugs as First-Line Treatment of Paroxysmal Atrial Fibrillation (RAAFT-2)A Randomized Trial

Presenter

PM

Summary

IMPORTANCE

Atrial fibrillation (AF) is the most common rhythm disorder seen in clinical
practice. Antiarrhythmic drugs are effective for reduction of recurrence in patients with
symptomatic paroxysmal AF. Radiofrequency ablation is an accepted therapy in patients for
whom antiarrhythmic drugs have failed; however, its role as a first-line therapy needs further
investigation.

OBJECTIVE

To compare radiofrequency ablation with antiarrhythmic drugs (standard
therapy) in treating patients with paroxysmal AF as a first-line therapy.
DESIGN, SETTING, AND PATIENTS A randomized clinical trial involving 127 treatment-naive
patients with paroxysmal AF were randomized at 16 centers in Europe and North America to
received either antiarrhythmic therapy or ablation. The first patient was enrolled July 27,
2006; the last patient, January 29, 2010. The last follow-up was February 16, 2012.

INTERVENTIONS

Sixty-one patients in the antiarrhythmic drug group and 66 in the
radiofrequency ablation group were followed up for 24 months.

MAIN OUTCOMES AND MEASURES

The time to the first documented atrial tachyarrhythmia of
more than 30 seconds (symptomatic or asymptomatic AF, atrial flutter, or atrial tachycardia),
detected by either scheduled or unscheduled electrocardiogram, Holter, transtelephonic
monitor, or rhythm strip, was the primary outcome. Secondary outcomes included
symptomatic recurrences of atrial tachyarrhythmias and quality of life measures assessed by
the EQ-5D tool.

RESULTS

Forty-four patients (72.1%) in the antiarrhythmic group and in 36 patients (54.5%)
in the ablation group experienced the primary efficacy outcome (hazard ratio [HR], 0.56
[95%CI, 0.35-0.90]; P = .02). For the secondary outcomes, 59%in the drug group and 47%
in the ablation group experienced the first recurrence of symptomatic AF, atrial flutter, atrial
tachycardia (HR, 0.56 [95%CI, 0.33-0.95]; P = .03). No deaths or strokes were reported in
either group; 4 cases of cardiac tamponade were reported in the ablation group. In the
standard treatment group, 26 patients (43%) underwent ablation after 1-year. Quality of life
was moderately impaired at baseline in both groups and improved at the 1 year follow-up.
However, improvement was not significantly different among groups.

CONCLUSIONS AND RELEVANCE

Among patients with paroxysmal AF without previous
antiarrhythmic drug treatment, radiofrequency ablation compared with antiarrhythmic drugs
resulted in a lower rate of recurrent atrial tachyarrhythmias at 2 years. However, recurrence
was frequent in both groups.

Supplementary Material

Supplementary material here.

Categories: Uncategorized

Journal Club 30 July 2014

Paper

Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis

Presenter

MD

Summary

Objective

To investigate whether revascularisation improves prognosis
compared with medical treatment among patients with stable coronary
artery disease.

Design

Bayesian network meta-analyses to combine direct within trial
comparisons between treatments with indirect evidence from other trials
while maintaining randomisation.
Eligibility criteria for selecting studies A strategy of initial medical
treatment compared with revascularisation by coronary artery bypass
grafting or Food and Drug Administration approved techniques for
percutaneous revascularization: balloon angioplasty, bare metal stent,
early generation paclitaxel eluting stent, sirolimus eluting stent, and
zotarolimus eluting (Endeavor) stent, and new generation everolimus
eluting stent, and zotarolimus eluting (Resolute) stent among patients
with stable coronary artery disease.
Data sources Medline and Embase from 1980 to 2013 for randomised
trials comparing medical treatment with revascularisation.
Main outcome measure All cause mortality.

Results

100 trials in 93 553 patients with 262 090 patient years of
follow-up were included. Coronary artery bypass grafting was associated
with a survival benefit (rate ratio 0.80, 95% credibility interval 0.70 to
0.91) compared with medical treatment. New generation drug eluting
stents (everolimus: 0.75, 0.59 to 0.96; zotarolimus (Resolute): 0.65, 0.42
to 1.00) but not balloon angioplasty (0.85, 0.68 to 1.04), bare metal
stents (0.92, 0.79 to 1.05), or early generation drug eluting stents
(paclitaxel: 0.92, 0.75 to 1.12; sirolimus: 0.91, 0.75 to 1.10; zotarolimus
(Endeavor): 0.88, 0.69 to 1.10) were associated with improved survival
compared with medical treatment. Coronary artery bypass grafting
reduced the risk of myocardial infarction compared with medical treatment
(0.79, 0.63 to 0.99), and everolimus eluting stents showed a trend
towards a reduced risk of myocardial infarction (0.75, 0.55 to 1.01). The
risk of subsequent revascularisation was noticeably reduced by coronary
artery bypass grafting (0.16, 0.13 to 0.20) followed by new generation
drug eluting stents (zotarolimus (Resolute): 0.26, 0.17 to 0.40;
everolimus: 0.27, 0.21 to 0.35), early generation drug eluting stents
(zotarolimus (Endeavor): 0.37, 0.28 to 0.50; sirolimus: 0.29, 0.24 to 0.36;
paclitaxel: 0.44, 0.35 to 0.54), and bare metal stents (0.69, 0.59 to 0.81)
compared with medical treatment.

Conclusion

Among patients with stable coronary artery disease,
coronary artery bypass grafting reduces the risk of death, myocardial
infarction, and subsequent revascularisation compared with medical
treatment. All stent based coronary revascularisation technologies reduce
the need for revascularisation to a variable degree. Our results provide
evidence for improved survival with new generation drug eluting stents
but no other percutaneous revascularisation technology compared with
medical treatment.

Supplmentary Material

Visualization of the revascularization strategies by end-point sensitivity analysis that is tabulated in the paper is available here.