A 37-year-old female with severe asthma was referred for additional management of palpitations and occasional syncopal spells. Her records include an electrocardiogram (ECG) with sinus rhythm and a first-degree atrioventricular (AV) block (PR interval 260 ms). An auto-triggered 30-day event monitor shows repeated episodes of atrial fibrillation (AF) that correlate with her symptoms. Her echocardiogram demonstrates a structurally normal heart.
Her syncopal spells have never lead to any serious injury, and in the past she has had a positive tilt table test with reproduction of syncope.
In discussing management strategy with her, she asks, “what is the best way to keep me in sinus rhythm for a long time?”
Show Answer
The correct answer is: D. Pulmonary vein isolation with radiofrequency ablation.
Randomized controlled trial data has demonstrated greater efficacy of maintaining sinus rhythm with ablation compared to antiarrhythmic drugs. In a study of 294 patients with paroxysmal atrial fibrillation (PAF), Nielsen et al. evaluated antiarrhythmic drugs versus ablation as the initial therapy for managing PAF. In that study more patients in the ablation group were free from any AF at 24 months (85% vs. 71% P=0.004) and from symptomatic AF (93% vs. 84% P=0.01) compared to those taking antiarrhythmic drugs.1 Similar findings favoring ablation were demonstrated by Morillo et al. in the recently published RAAFT-2 (Radiofrequency Ablation vs. Antiarrhythmic Drugs as First-Line Treatment of Paroxysmal Atrial Fibrillation) study that also evaluated ablation as first choice therapy drugs in PAF.2
Beta-blockers are the most likely drug to rate control a patient with episodes of AF; however, they do not help maintain sinus rhythm (option A). In addition, her history of severe asthma raises the question of possible worsening of her asthma control with the use of metoprolol. Propafenone (option B) is less effective than amiodarone in maintaining sinus rhythm.3 Given her young age, the toxicities associated with amiodarone make it a difficult choice (option C). In addition, her PR prolongation increases the risk of bradyarrhythmia during antiarrhythmic drug therapy.4
References
Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 2012;367:1587-95.
Morillo CA, Verma A, Connolly SJ, et al. on behalf of the RAAFT-2 Investigators. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. JAMA 2014;311:692-700.
Zimetbaum P. Antiarrhythmic drug therapy for atrial fibrillation. Circulation 2012;125:381-9.
January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014 Mar 28; [Epub ahead of print].
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