Efficacy of Antiarrhythmic Drugs Short-Term Use After Catheter Ablation for Atrial Fibrillation - EAST-AF

Description:

The goal of the trial was to assess the efficacy of routine short-term antiarrhythmic drug (AAD) use after pulmonary vein isolation (PVI) for atrial fibrillation (AF).

Contribution to the Literature: The EAST-AF trial showed that routine short-term use of class I or III AADs following PVI for AF does not result in a greater reduction in the incidence of tachyarrhythmias at 1 year compared with routine management.

Study Design

Patients were randomized in a 1:1 fashion to either routine Vaughan Williams class I (75%) or III (25%) AAD for 90 days (n = 1,016), or routine management (n = 1,007).

  • Total number of enrollees: 2,038
  • Duration of follow-up: 1 year
  • Mean patient age: 63 years
  • Percentage female: 25%

Other salient features/characteristics:

  • Paroxysmal AF: 67%, persistent: 23%
  • CHADS2 score 0-1: 74%
  • Left ventricular ejection fraction: 65%
  • Left atrial diameter: 39 mm
  • Prior ineffective AAD: 0 (40%), 1 (40%), ≤3 (5%)

Inclusion criteria:

  • Age 21-79 years
  • First-time radiofrequency catheter ablation for paroxysmal, persistent, or long-lasting AF

Exclusion criteria:

  • Contraindication or intolerance to adenosine triphosphate or Vaughan Williams class I or III AADs including severe asthma, severe vasospastic angina, and substantial bradycardia
  • Renal insufficiency (serum creatinine ≥2.0 mg/dl or on hemodialysis)
  • New York Heart Association class IV heart failure
  • Left ventricular ejection fraction 40%
  • Left atrial diameter >55 mm
  • Very long-lasting (≥5 years) AF
  • Intolerance for optimal anticoagulation
  • Myocardial infarction within the past 6 months
  • Prior or planned open heart surgery
  • Severe valvular heart disease

Principal Findings:

The primary outcome, freedom from recurrent tachyarrhythmias at 1 year (minus 90-day blanking period) for AAD use vs. routine management, was 69.5% vs. 67.8% (hazard ratio 0.93, 95% confidence interval 0.79-1.09, p = 0.36).

Secondary outcomes (for AAD use vs. routine management):

  • Freedom from recurrent tachyarrhythmias at 90 days: 61.1% vs. 53.5%, p = 0.01
  • All-cause mortality: 0.3% vs. 0.2%
  • Stroke/systemic embolism: 0.3% vs. 0.2%
  • Direct current cardioversion: 11.1% vs. 11.5%
  • Side effects of AAD requiring dose change or discontinuation: 4.1%

Interpretation:

The results of this trial indicate that routine short-term (90-day) use of class I or III AADs following PVI for AF does not result in a greater reduction in the incidence of tachyarrhythmias at 1 year, despite a benefit at 90 days. An interesting paradox is that patients who had a recurrence within 90 days were at a significantly higher risk of having recurrent tachyarrhythmias at 1 year.

This trial confirms findings from other smaller trials on this topic. It is unclear if longer duration of AAD use would be more beneficial, although they are associated with side effects and may negate one of the patient-centric advantages of PVI (freedom from AAD use). Note: There was a computer error in randomization in this trial, resulting in an imbalance in some of the baseline characteristics, and the analyses had to be adjusted accordingly.

References:

Kaitani K, Inoue K, Kobori A, et al. Efficacy of Antiarrhythmic Drugs Short-Term Use After Catheter Ablation for Atrial Fibrillation (EAST-AF) trial. Eur Heart J 2015;Sep 28:[Epub ahead of print].


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