When AFib Persists, Early Ablation May Help You More Than Meds

Study says best when done within first year
When AFib Persists, Early Ablation May Help You More Than Meds

Medication can often ease the frightening symptoms you have with atrial fibrillation, or AFib. The pounding heart (palpitations). The difficulty breathing. The dizziness.

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“Medications are considered a reasonable first-line treatment in many scenarios,” says cardiologist Ayman Hussein, MD.

“But when AFib lasts for more than seven days — or lasts more than two days but requires an electrical shock to restore normal rhythm — we often get better results when we use a more invasive treatment early on.”

That treatment is ablation — which delivers energy, often from heat, to small areas of the heart’s top chamber (atrium). That’s where abnormal electrical signals originate, disrupting the heart’s rhythm.

Research suggests ablation improves symptoms for most patients with persistent AFib.

Dr. Hussein believes ablation does a better job of targeting the root problem, rather than simply treating the symptoms.

“Using medication is like applying a Band-Aid® to see if symptoms stop,” he says. “We tell our patients that ablation takes a more definitive shot at the source of the problem.

“Success rates are very good, and the procedure is safe — especially at healthcare centers that do a large number of ablations.”

Vast majority find symptom relief

Cleveland Clinic doctors are sending surveys asking patients who received ablation to describe how they felt after the procedures.

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Of the 2,503 patients who underwent ablation between 2013 and 2016, “about 70 to 80 percent had remarkable improvement in symptoms,” Dr. Hussein says. “Twenty percent reported improvement that was mild or moderate. ER visits declined significantly, and hospital readmission rates went down.”

Less than 10 percent reported no improvement or worsening symptoms. “This might reflect the natural progression of the underlying disease process,” he says.

Another recent study, involving patients from Europe, Australia and the United States, addressed ablation in patients who had heart failure and AFib.

It found that after ablation, fewer patients either were hospitalized with worsening heart failure, or died, compared with patients receiving medication.

Why study an alternative to medication?

With medication, AFib often returns over time.

“Medications control AFib, but don’t necessarily target the cause,” Dr. Hussein says. “We don’t have perfect drugs for it; they may or may not work, and they have potential side effects.”

  • Amiodarone, for example, is potent but tough on the liver, lungs, thyroid and eyes — especially with long-term use, he says.
  • Dofetilide is a drug second only to amiodarone in its potency and ability to control AFib. But doctors must start it in the hospital to make sure patients can tolerate it (too high a dose can cause serious rhythm problems and stop the heart). It can also interact with other drugs.
  • Sotalol affects the electrical recovery of the heart between squeezes and must also be started in the hospital due to concerns about serious heart rhythm issues. Sotalol is not appropriate when your heart muscle is weak.

In addition, both dofetilide and sotalol are cleared by the kidneys, and can cause additional problems for patients with kidney issues, he notes.

Better outcomes with early ablation

Ablation can improve outcomes, but the timing of treatment matters.

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“We looked at the time from diagnosis of persistent AFib to the time of ablation and saw that the sooner the interventions were done, the better,” Dr. Hussein says.

“The best outcomes we saw were with patients who were ablated in the first year after they were first diagnosed with persistent AFib.”

When ablations were performed after longer waiting times, the atria tended to enlarge, stress on the heart increased, and markers of inflammation rose, he notes.

Advice for new patients

If you have been diagnosed with AFib, it’s a good idea to discuss all the options with your doctor early on, advises Dr. Hussein.

“We inform patients that medication and ablation are both acceptable first-line strategies,” he says. “We share the data, and what we know about early and late interventions; but, in the end, it is the patient’s decision.”

He adds, “Although the medication strategy is noninvasive — which some patients prefer — it’s more of a Band-Aid approach that doesn’t address the root cause.”

The data show that the irregular heartbeat does not recur in about 65 percent of patients who have ablation for persistent AFib. About 20 percent may require a touch-up to improve their success rate, he notes.

Meanwhile, research continues on the benefits versus the risks of using ablation as first-line treatment for persistent AFib. But, “thus far, the published evidence shows better outcomes with ablation,” concludes Dr. Hussein.

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