PulmOnary vein isolation With vs. without continued antiarrhythmic Drug trEatment in subjects with Recurrent Atrial Fibrillation - POWDER AF

Contribution To Literature:

The POWDER AF trial showed that continuation of antiarrhythmic drug therapy was superior at preventing recurrent atrial tachyarrhythmias.

Description:

The goal of the trial was to evaluate continuation of antiarrhythmic drug therapy compared with discontinuation among patients with paroxysmal atrial fibrillation who underwent pulmonary vein isolation.

Study Design

  • Randomized
  • Parallel

Patients with paroxysmal atrial fibrillation resistant to antiarrhythmic drug therapy who underwent pulmonary vein isolation were randomized to continued antiarrhythmic drug therapy (n = 77) versus discontinuation of antiarrhythmic drug therapy (n = 76). Patients were eligible to participate if they were in normal sinus rhythm 3 months after pulmonary vein isolation.

  • Total number of enrollees: 153
  • Duration of follow-up: 12 months
  • Mean patient age: 63 years
  • Percentage female: 26%
  • Percentage with diabetes: 8%

Inclusion criteria:

  • Paroxysmal atrial fibrillation
  • Resistant to antiarrhythmic drug therapy
  • Undergoing pulmonary vein isolation

Exclusion criteria:

  • Advanced structural heart disease
  • Left atrial diameter >55 mm
  • Ejection fraction <35%
  • Coronary artery bypass grafting or myocardial infarction within the last 3 months
  • Unstable angina, uncontrolled heart failure, awaiting cardiac transplantation or cardiac surgery
  • Life expectancy <12 months
  • Acute illness
  • Enrollment in another study evaluating substrate ablation during the initial procedure
  • Women of childbearing potential

Principal Findings:

The primary outcome, incidence of atrial tachyarrhythmia >30 seconds, occurred in 2.7% of the continue antiarrhythmia group versus 21.9% of the discontinue antiarrhythmia group (p < 0.001).

Secondary outcomes:

  • Repeat ablation: 1.4% vs. 19.2% (p < 0.001), respectively, for continuation vs. discontinuation of drug therapy
  • No difference in quality of life or symptoms between treatment groups

Interpretation:

Among patients with paroxysmal atrial fibrillation who underwent pulmonary vein isolation and were in normal sinus rhythm 3 months after the procedure, continuation of antiarrhythmic drug therapy was effective at reducing recurrence of atrial tachyarrhythmia compared with discontinuation of drug therapy. The frequency of repeat ablation was also lower in the continuation of drug therapy group. Quality of life and symptoms were similar between treatment groups.

References:

Duytschaever M, Demolder A, Phlips T, et al. Pulmonary vein isolation with vs. without continued antiarrhythmic drug treatment in subjects with recurrent atrial fibrillation (POWDER AF): results from a multicentre randomized trial. Eur Heart J 2017;Dec 2:[Epub ahead of print]

Clinical Topics: Arrhythmias and Clinical EP, Prevention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Pulmonary Veins, Quality of Life, Recurrence, Secondary Prevention, Tachycardia


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