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Cardiovascular Report - Deciding the Right Treatment for Atrial Fibrillation

Cardiovascular Report, Summer 2012

Deciding the Right Treatment for Atrial Fibrillation

Date: June 15, 2012

Hugh Calkins
Hugh Calkins, lead author of the new consensus statement, says experts from around the world helped shape the document.
photo by Keith Weller

When Kathleen Kennedy traveled from her home in St. Louis to Johns Hopkins last February, she was seeking relief from severe symptoms of atrial fibrillation (AF) that had sidelined her from her usual, active life. “I wasn’t functional,” says the 70-year-old former long-distance runner. “I was having frequent episodes when my heart rate was so high, I had to lie down. I had no energy and it was controlling my life because I didn’t know when the symptoms would strike again.”

Her symptoms began 20 years ago and were well controlled by medication until last year, when the episodes became more frequent. She was hospitalized with one episode that persisted for five days.

Kennedy was referred to Hugh Calkins, director of the cardiac arrhythmia service and electrophysiology at Hopkins. “Because she was highly symptomatic and antiarrhythmic medications had stopped working, she was an optimal candidate for catheter ablation to control her atrial fibrillation and improve her quality of life,” says Calkins.

Since AF is one of the most common heart rhythm disorders, affecting more than 2.5 million Americans and millions more around the world, catheter and surgical ablations for AF are being offered at more hospitals across the country. Patient selection, procedure techniques, management and follow-up are all crucial for providing the best care.

Calkins is the lead author of the just-completed Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation, published by the Heart Rhythm Society in partnership with the European Heart Rhythm Association and the European Cardiac Arrhythmia Society. It was endorsed by the American Heart Association, the American College of Cardiology and the Society of Thoracic Surgery.

The document is the first to define the indications for catheter and surgical ablation of atrial fibrillation based on the type of AF, the patient’s symptoms and the response to antiarrhythmic drug therapy. It is also a comprehensive review of the field of AF ablation and defines the indications, techniques and outcomes of these procedures.

“Our goal is to provide clear standards based on the best available evidence in order to ensure safety and improve the care of patients with atrial fibrillation,” says Calkins.

In the new consensus statement’s indications for treatment, Kennedy fell within class 1, level A, because she was symptomatic, and her paroxysmal AF was refractory to antiarrhythmic medication. In that category, catheter ablation is recommended based on results of multiple prospective, randomized trials, as long as the procedure is performed by an experienced electrophysiologist who has received appropriate training and is performing the ablation in a high-volume center.

The consensus statement provides a roadmap for deciding when catheter or surgical ablation is recommended, is reasonable or should not be performed for patients in other categories, such as those who have longstanding persistent AF of many years’ duration and those who are asymptomatic.

Calkins says following ablation, patients such as Kennedy would have a 70 to 80 percent chance of being symptom-free over the next five years. And if their symptoms returned, they’d likely be more mild. Calkins stresses that patients must continue to be followed regularly because even though catheter ablation is highly effective in treating patients with AF, it cannot be considered a permanent cure for all.

Kennedy underwent catheter ablation at Hopkins in February. She stayed one night in the hospital, walked around a Baltimore museum the next day and flew home to St. Louis the day after that. For her, the results were excellent. “It’s amazing what this procedure has done for me. My energy and enthusiasm—my whole life is back,” she says. “I feel much better than I have in a long time.”

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