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Randomized Controlled Trial
. 2021 Mar 8;23(3):362-369.
doi: 10.1093/europace/euaa298.

Catheter ablation or medical therapy to delay progression of atrial fibrillation: the randomized controlled atrial fibrillation progression trial (ATTEST)

Karl-Heinz Kuck  1 , Dmitry S Lebedev  2 , Evgeny N Mikhaylov  2 , Alexander Romanov  3 , László Gellér  4 , Oskars Kalējs  5 , Thomas Neumann  6 , Karapet Davtyan  7 , Young Keun On  8 , Sergey Popov  9 , Maria Grazia Bongiorni  10 , Michael Schlüter  11 , Stephan Willems  1   2 , Feifan Ouyang  1
Affiliations
Randomized Controlled Trial

Catheter ablation or medical therapy to delay progression of atrial fibrillation: the randomized controlled atrial fibrillation progression trial (ATTEST)

Karl-Heinz Kuck et al. Europace. .

Abstract

Aims: Delay of progression from paroxysmal to persistent atrial fibrillation (AF) is an important measure of long-term success of AF treatment. However, published data on the impact of catheter ablation on AF progression are limited. This study evaluates whether radiofrequency (RF) catheter ablation delays the progression of AF compared with antiarrhythmic drug (AAD) treatment using current AF management guidelines.

Methods: This prospective, randomized, controlled, two-arm, open-label trial was conducted at 29 hospitals and medical centres across 13 countries. Patients were randomized 1 : 1 to RF ablation or AAD treatment. The primary endpoint was the rate of persistent AF/atrial tachycardia (AT) at 3 years.

Results: After early study termination following slow enrolment, 255 (79%) of the planned 322 patients were enrolled (RF ablation, n = 128, AAD, n = 127); 36% of patients in the RF ablation group and 41% in the AAD group completed 3 years of follow-up. For the primary endpoint, the Kaplan-Meier estimate of the rate of persistent AF/AT at 3 years was significantly lower with RF ablation [2.4% (95% confidence interval (CI), 0.6-9.4%)] than with AAD therapy [17.5% (95% CI, 10.7-27.9%); one-sided P = 0.0009]. Patients ≥65 years were ∼4 times more likely to progress to persistent AF/AT than patients <65 years, suggesting RF ablation can delay disease progression [hazard ratio: 3.87 (95% CI, 0.88-17.00); P = 0.0727]. Primary adverse events were reported for eight patients in the RF ablation group.

Conclusions: Radiofrequency ablation is superior to guideline-directed AAD therapy in delaying the progression from paroxysmal to persistent AF.

Keywords: Antiarrhythmic drugs; Atrial tachycardia; Persistent atrial fibrillation; Progression; Radiofrequency ablation.

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Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Patient disposition. AAD, antiarrhythmic drug; ITT, intention-to-treat; PP, per-protocol; RF, radiofrequency.
Figure 2
Figure 2
Time to primary endpoint (occurrence of persistent atrial fibrillation/tachycardia) by treatment group: (A) ITT patient cohorts, (B) PP patient cohorts, (C) as-treated patient cohorts, and (D) ITT patient cohorts using the 2017 expert consensus Heart Rhythm Society definition of persistent atrial fibrillation. Note adherence to 90-day (0.25 year) blanking period in all panels. AAD, antiarrhythmic drug therapy; AF, atrial fibrillation; AT, atrial tachycardia; ITT, intention-to-treat; PP, per-protocol; RF, radiofrequency.
Figure 3
Figure 3
Association of baseline conditions with the occurrence of persistent AF/AT (ITT population). AAD, antiarrhythmic drug treatment; AF, atrial fibrillation; AT, atrial tachycardia; CI, confidence interval; COPD, chronic obstructive pulmonary disease; ITT, intention-to-treat; LA, left atrial; RF, radiofrequency; TIA, transient ischaemic attack.
See this image and copyright information in PMC

References

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