AF Management: Rhythm Control as Early as Possible – But What Does “Early” Really Mean? Use Your Judgement

Oussama Wazni, MD, MBA

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Oussama Wazni, MD, MBA, from the Cleveland Clinic, discusses his presentation entitled "AF Management: Rhythm Control as Early as Possible – But What Does “Early” Really Mean? Use Your Judgement" during Session 14 at the Western AF Symposium 2024. 

Kevin Makati, MD: We're going to get started here on session 14. It's a pleasure to cochair with Narendra Kanuru. We have a fantastic bunch of speakers and presentations. Our first speaker is Dr Oussama Wazni from the Cleveland Clinic on early atrial fibrillation (AF) and rhythm control.

Oussama Wazni, MD, MBA: Thank you. So, the title of this presentation is “AF Management: Rhythm Control as Early as Possible – But What Does “Early” Really Mean? Use Your Judgement.” Not AI, not yet at least. You'll see why we're talking about using your judgment to guide us on who to ablate sooner than later. It's very important to mention, and I think a lot of talks have gone through this earlier, that risk factor modification is the fundamental basis of managing AF. You saw that there was a big intersection on diastolic dysfunction, diabetes, and obesity with AF, so all these have to be managed. I really believe we must make a good diagnosis. Now, whether it’s with an Apple Watch or with a medical grade monitor, that would be better. But if you’re going to intervene on a patient, you had better be sure that they really do have AF because sometimes I get patients now referred for AF ablation and I cannot find a single ECG that shows AF. So, it's very important to make sure that you have the right diagnosis and it's documented somewhere. But then, it’s very important to follow up with those patients very well and know how they're doing, because if we don't measure how we're doing, we cannot get any better. So, it's important for us to have follow-up on these patients. 

Why is it important to ablate sooner than later, or at least get rhythm control sooner than later? I'll show you why ablation is better than other modalities, namely medical therapy. It is because, and I think you've seen this slide many times over, so I'm not going to spend too much time, but what happens is you get more frequent AF, and then as the episodes become more frequent, they become longer, and then you get into persistent and then permanent AF.

The usual way we do things is to do a cardioversion and then start them on an antiarrhythmic drug. If they fail, then we do an ablation. Now, the reason why I decided to look at this is because we took some patients after being stable on medications for a long period of time, we took them to the lab, and found that these patients already had scar tissue in the left atrium. This is why this slide is here. So, the question was maybe we should have ablated sooner because whatever was going on in that atrium continued to progress despite antiarrhythmic drug therapy and maintenance of sinus rhythm. So again, this causes all the AF remodeling and favors arrhythmia. 

What are the goals of AF ablation? Relief of symptoms, improved quality of life, and prevention of progression. These are new. Symptoms and quality of life are the standard of why we do ablations, but there is also prevention of progression, prevention of heart failure, stroke, mortality, and reduction in cost of care. I'll show you some slides to emphasize those points. 

This was a concept that was started early on. Actually, we were among the first who described diagnosis-to-ablation time. The one in the middle is our study showing that if you ablate within 1 year of diagnosis of AF, the outcomes are very good. If you wait longer than 1 year, the outcomes are not very good. Others have shown it on the left and right, as you can see there. 

Now, again, there's been a lot of talk this morning that the CHA₂DS₂-VASc score is not very helpful. I mean, it is helpful, but it's not something that you can hang your hat on. The type of AF is not in the CHA₂DS₂-VASc score. As you can see here, this is work from Korea, that with nonparoxysmal AF, the risk of stroke is much higher. So, how does this go with early AF ablation? If you can do early AF ablation and prevent progression to persistent AF, then you can reduce the risk of stroke. 

How about the impact of AF on the risk of thromboembolism, mortality, and bleeding? This was from Ganesan et al and it shows that, again, if you have nonparoxysmal AF, mainly persistent or permanent AF, then the risk of all of these is much higher.

This is our early study. This was from 2009. We took these patients with persistent AF, looked at diagnosis-to-ablation time, and found that left atrial size increases as we went from 1 year to between 1 and 3 years, 3 to 6 years, or more than 6 and a half years. BNP levels go up, and there was a lot of discussion this morning on BNP also predicting stroke. The CRP actually goes up and then flattens out. I think what happens at the end is that the inflammation subsides because it's burned out. These patients have been in AF for so long that they burned out. Walid Saliba just showed me a case in which the patient has always been in AF, and after more than 6 years of being in AF, is now in sinus rhythm on his own. It's very rare, but it can happen. 

We went through this slide, and again, this was just now in 2024, so from our study in 2009, and this one from China showing, again, the same concept that the sooner we ablate, the better the outcomes in these patients.

This is work from Nassir Marrouche, and it shows that if we wait, there'll be progression of scar tissue or fibrosis in the left atrium. We've shown now that the more fibrosis there is, the less successful we are in managing these patients. 

A long time ago, this is almost ancient history, there was the stepwise approach, but even with patients who terminate AF, and those patients who have been in AF for a long time, look at their outcomes at 24 months. It’s just 20% and 40%.  

I’m not going to spend too much time on STAR AF II by Atul Verma. It also showed that if you have patients who are progressing, then whatever you add will not help. That is why I think what we need to do is get AF sooner than later. This is a very good study called the CAMERA-MRI trial and this is in patients who have rate-controlled AF but then develop fibrosis. So, this is not tachycardia-induced cardiomyopathy. This is AF that is rate controlled and those arrows are pointing to scar in the left ventricle. They showed that if you restore sinus rhythm in rate-controlled AF, you can improve ejection fraction in a majority of patients, provided that they don't have a lot of scar in the left ventricle. 

This is the EAST-AFNET trial. I think everybody now has memorized this, so I'm not going to spend too much time on it. But just to show here that early rhythm control is much better than usual care in the reduction of stroke, mortality, and also in heart failure. Most of those patients are managed with antiarrhythmic drugs, and not with ablation. 

Now, we’re going to go with ablation. If you want to compare ablation with antiarrhythmic drugs, this is from the ATTEST study showing that ablation decreases the risk of progression compared to antiarrhythmic medications. Actually, it's something that I had discussed in our own patients. Patients would be doing well for many years and then start having AF. We ablated them but we would find that they already had a lot of scar tissue on the posterior wall, and it was difficult to control. So that's why we started thinking about this.

This slide is about subclinical AF. Again, if we allow patients to continue to have subclinical AF, the risk of heart failure and hospitalization increases with time. 

Again, from Nassir Marrouche, the CASTLE study showed for the first time that ablation decreases mortality.

I have to speed up here, but you all know about STOP AF First and also the EARLY-AF trials basically showing that ablation is much better than antiarrhythmic drugs in drug-naive patients as first-line therapy and there was improvement in quality of life in all aspects. 

This one is from Jason Andrade and showed the same thing. Both studies were in the same issue of the New England Journal of Medicine.

This is Cryo-FIRST. This came just after our studies basically showing the same results, that ablation is much better than antiarrhythmic drugs for maintenance of sinus rhythm. We had the data on all these patients, so we did a patient-specific meta-analysis. This was not publication meta-analysis, patient-specific. Again, we showed that with ablation, you decrease the risk of recurrence, the risk of hospitalization, and also health care utilization. 

I'm going to skip these slides because they go through the same. But again, this is very importantly from Jason Andrade. It's really very rare for the same group of patients to be in 2 New England Journal of Medicine papers, but because he implanted loop recorders, he was able to show that with ablation, you can reduce the progression from paroxysmal AF to persistent AF.

I'm going to skip this slide because this is just a registry on patients who have DOACs. Some patients had an ablation, but you can see those reductions, 50% and 55% reductions, in the composite outcome of all-cause death, stroke, and major bleeding, and reduction in all-cause death in those patients who had an ablation. 

So, what are the barriers? Naysayers, you can read them there for yourselves. Is the threshold to have an ablation going to become lower? I think it is with pulsed field ablation. Conclusion? First-line ablation is an effective and important strategy, and should be considered for first-line therapy in everyone. Thank you.

The transcripts have been edited for clarity and length.