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Updated: Jun 28, 2025
Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Prognostic Impact of Sinus Rhythm in Atrial Fibrillation Patients: Separating Rhythm Outcomes From Randomized
T Jared Bunch1, Jeanne E Poole2, Adam P Silverstein3
1Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City (T.J.B.).
Insights
Maintaining sinus rhythm (SR) significantly reduces mortality and adverse cardiovascular events in atrial fibrillation (AF) patients. This benefit is independent of whether catheter ablation or drug therapy is used for rhythm control.
Area of Science:
- Cardiology
- Electrophysiology
- Clinical Trials
Background:
- Atrial fibrillation (AF) significantly increases mortality and cardiovascular risks.
- Restoring sinus rhythm (SR) may mitigate these adverse effects, but the optimal method is debated.
Purpose of the Study:
- To assess the prognostic benefits of SR in AF patients.
- To determine if the method of achieving SR (ablation vs. drugs) influences outcomes.
Main Methods:
- Analysis of 1240 patients from the CABANA trial with detailed rhythm monitoring.
- Cox survival modeling with heart rhythm as a time-dependent variable.
Main Results:
- Increased time in SR was associated with a significantly reduced risk of the primary composite endpoint (death, stroke, bleeding, cardiac arrest).
- The protective effect of SR was independent of the treatment strategy (catheter ablation vs. antiarrhythmic drugs).
Conclusions:
- Maintaining SR in AF patients leads to a clinically significant reduction in mortality and adverse events.
- The benefits of SR are independent of the therapeutic approach used to achieve it.
Background:
Clinically detected atrial fibrillation (AF) is associated with a significant increase in mortality and other adverse cardiovascular events. Since the advent of effective methods for AF rhythm control, investigators have attempted to determine how much these adverse prognostic AF effects could be mitigated by the restoration of sinus rhythm (SR) and whether the method used mattered.
Methods:
The CABANA trial (Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation) randomized 2204 AF patients to ablation versus drug therapy, of which 1240 patients were monitored in follow-up using the CABANA ECG rhythm monitoring system. To assess the prognostic benefits of SR, we performed a prespecified analysis using Cox survival modeling with heart rhythm as a time-dependent variable and randomized treatment group as a stratification factor.
Results:
In the 1240 patient study cohort, 883 (71.2%) had documented AF at some point during their postblanking follow-up. Among the 883 patients, 671 (76.0%) experienced AF within the first year of postblanking follow-up, and 212 (24.0%) experienced their first AF after ≥1 year of postblanking follow-up. The primary CABANA end point (death, disabling stroke, serious bleeding, or cardiac arrest) occurred in 95 (10.8%) of the 883 patients with documented AF and in 29 (8.1%) of the 357 patients with no AF recorded during follow-up. In multivariable time-dependent analysis, the presence of SR (compared with non-SR) was associated with a significantly reduced risk of the primary end point (adjusted hazard ratio, 0.57 [95% CI, 0.38-0.85]; P=0.006; independent of treatment strategy [ablation versus drugs]). Corresponding results for all-cause mortality were adjusted hazard ratio of 0.59 [95% CI, 0.35-1.01]; P=0.053).
Conclusions:
In patients in the CABANA trial with detailed long-term rhythm follow-up, increased time in SR was associated with a clinically consequential decrease in mortality and other adverse prognostic events. The predictive value of SR was independent of the therapeutic approach responsible for reducing the burden of detectable AF.
Registration:
URL: https://clinicaltrials.gov; Unique Identifier: NCT00911508.
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