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Atrial fibrillation (AF) is a progressive disease. Progression occurs not only because the patient's risk factors for AF gradually worsen, but also likely because AF itself modifies the atrial substrate. In the randomized, manufacturer-supported EARLY-AF trial (NCT02825979), investigators compared an early-ablation strategy with antiarrhythmic-drug therapy in reducing the risk for persistent AF, with 1-year follow-up data published previously (NEJM JW Cardiol Jan 2021 and N Engl J Med 2021; 348:305 and 316). Now, the investigators have reported 3-year follow-up results.
All 303 patients with paroxysmal AF assigned to either initial cryoablation or antiarrhythmic-drug therapy were given implantable loop monitors to assess for total density of AF. Within 3 years, an episode of persistent AF occurred in 3 patients (1.9%) in the ablation group and 11 patients (7.4%) in the drug-therapy group (hazard ratio, 0.25; 95% CI, 0.09–0.70); the groups' median percentages of time in AF were 0% and 0.24%, respectively. Adverse events also were significantly less common in the ablation group than the drug-therapy group (11.0% vs. 23.5% of patients).
Andrade JG et al. Progression of atrial fibrillation after cryoablation or drug therapy. N Engl J Med 2022 Nov 7; [e-pub]. (https://doi.org/10.1056/NEJMoa2212540)
Comment
Accumulating data suggest that early treatment of AF limits progression. It's not surprising that ablation is more effective than antiarrhythmic-drug therapy in mitigating AF progression given that multiple randomized, controlled trials have shown ablation's greater efficacy in preventing AF. Appropriate candidates for ablation should consider it — to mitigate not only symptoms, but also progression of disease.