NEWMARKET, ONTARIO, CANADA. The debate over whether catheter ablation or ongoing treatment with antiarrhythmic drugs (AADs) should be first-line treatment for symptomatic atrial fibrillation (AF) is still continuing. Several clinical trials have now concluded that catheter ablation is significantly more effective in re-establishing and maintaining sinus rhythm than is treatment with AADs. The Canadian RAAFT study found that 63% of patients with symptomatic, paroxysmal AF treated with catheter ablation experienced no afib recurrence during the first year following their procedure. This compares to only 13% of patients on AADs experiencing no episodes during their first year on the drugs (mainly flecainide and propafenone).

A group of researchers led by Drs. Yaariv Khaykin and Atul Verma of the Southlake Regional Health Center now report on the relative cost effectiveness of the two approaches. They used the following costs ($ Canadian) for the ablation and drugs (these are the fees actually paid to the hospitals and doctors by the provincial ministries of health on behalf of patients covered by the Canadian Health Care Plan):

• Ablation* - $ 8,607
• Cardioversion - $ 1,674
• Overnight stay on a telemetry unit - $ 596
• Anticoagulation - $ 132/month
• Flecainide - $ 90/month
• Propafenone - $ 93/month
• Amiodarone - $ 39/month
• Sotalol - $ 39/month
• Beta-blocker - $ 10/month
• Calcium channel blocker - $ 28/month

* This includes an overnight hospital stay, a TEE prior to ablation, catheter cost and cost of a 4-hour use of electrophysiology laboratory as well as physician fees, cost of 2 CT scans, a loop event recorder and a 24-hour Holter monitor (one before discharge, and one at 3, 6 and 12 months each).

During the first year of follow-up (from ablation or initiation of drug therapy) only 9% of ablated patients were re-admitted to hospital versus 54% of patients on AADs. Similarly, 63% of ablated patients (no repeat ablations allowed during first year) remained in sinus rhythm during the first year compared to only 13% in the AAD group. The total initial treatment cost was $10,465 for ablation patients versus $2,556 for patients randomized to AADs. During the first year follow-up incremental costs were $2,358 in the ablation group versus $3,497 in the AAD group.

During the 2nd year repeat ablations were allowed for those in the ablation group and those in the AAD group who had not been helped by drugs were also allowed to undergo an ablation. This brought the incremental cost in the 2nd year to $2,480 per original ablation patient versus $8,339 per original AAD patient. At the end of the 2nd year total expenditure for patients starting out with an ablation was $15,303 versus $14,392 for those starting out with AADs.

The researchers conclude that radiofrequency ablation in patients with symptomatic, paroxysmal AF is cost neutral 2 years following the initial procedure compared to treatment with antiarrhythmic drugs.

Khaykin, Y, et al. Cost comparison of ablation versus antiarrhythmic drugs as first-line therapy for atrial fibrillation. Journal of Cardiovascular Electrophysiology, Vol. 20, January 2009, pp. 7-12

Editor's comment: Although not considered in this particular study, it is also clear that the quality of life among members of the ablation group would have been substantially superior to that experienced in the AAD group during the 2-year follow-up. Indeed, this study provides convincing evidence that undergoing an ablation early in one's afib "career" is a win/win situation provided that the procedure is performed by a highly skilled and experienced EP, and that natural therapies (supplementation, diet changes) have failed to keep afib under control.