Occurrence and Characteristics of Stroke Events in the Atrial Fibrillation Follow-up Investigation of Sinus Rhythm Management (AFFIRM) Study

Sherman, David G.; Kim, Soo G.; Boop, Bradley S.; Corley, Scott; DiMarco, John P.; Hart, Robert G.; Haywood, L. Julian; Hoyte, Keith; Kaufman, Elizabeth S.; Kim, Michael; Nasco, Elaine; Waldo, Albert L.

doi:10.1001/archinte.165.10.1185

Cited by 208 publications

(56 citation statements)

References 25 publications

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“…A separate search of the literature was undertaken to identify additional evidence related to the prognostic value of NSR in patients with AF. The search identified an analysis of the AFFIRM study, which examined the occurrence and characteristics of stroke events in their investigation of sinus rhythm management, and provided an estimate of the hazard of stroke for AF relative to NSR 14. Using a Cox proportional hazards regression analysis, the presence of AF was found to be significantly associated with a 60% increase in the risk of stroke after adjusting for several covariates including the use of warfarin therapy.…”

Section: Methodsmentioning

confidence: 99%

Cost-effectiveness of radiofrequency catheter ablation for the treatment of atrial fibrillation in the United Kingdom

McKenna

Palmer

Rodgers

et al. 2008

Heart

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Objective: To assess the cost-effectiveness of radiofrequency catheter ablation (RFCA) compared with antiarrhythmic drug (AAD) therapy for the treatment of atrial fibrillation (AF) from the perspective of the UK NHS. Design: Bayesian evidence synthesis and decision analytical model. Methods: A systematic review and meta-analysis was conducted and Bayesian statistical methods used to synthesise the effectiveness evidence from randomised control trials. A decision analytical model was developed to assess the costs and consequences associated with the primary outcome of the trials over a lifetime time horizon. Main outcome measure: Costs from a health service perspective and outcomes measured as quality-adjusted life years (QALYs). Results: The incremental cost-effectiveness ratio of RFCA varied between £7763 and £7910 for each additional QALY according to baseline risk of stroke, with a probability of being cost-effective from 0.98 to 0.99 for a cost-effectiveness threshold of £20 000. Results were sensitive to the duration of quality of life benefits from treatment. Conclusions: RFCA is potentially cost-effective for the treatment of paroxysmal AF in patients' predominantly refractory to AAD therapy provided the quality-of-life benefits from treatment are maintained for more than 5 years. These findings remain subject to limitations in the existing evidence regarding the nature of life benefits and the prognostic importance of restoring normal sinus rhythm conferred using RFCA.Atrial fibrillation (AF) is a common and debilitating cardiac arrhythmia. Its prevalence in the United Kingdom is rising as a result of an ageing population and an increased longevity resulting from improved medical care for chronic cardiac conditions which predispose to AF.1 A recent report estimated that approximately 1% of all NHS expenditures are the result of AF.2 The costeffective management of AF in the United Kingdom therefore represents an important consideration.Radiofrequency catheter ablation (RFCA) is an established technique for the treatment of cardiac arrhythmias, which has relatively recently been extended to allow treatment of AF. In the United Kingdom, its use for controlling AF is recommended by the National Institute for Health and Clinical Excellence (NICE) for patients who have previously failed on other management strategies.3 RFCA offers the potential to eliminate the underlying cause of AF, which other therapies fail to achieve. The primary outcome from the procedure is the restoration and maintenance of normal sinus rhythm (NSR). The sustained long-term maintenance of sinus rhythm establishes the efficacy of the intervention.RFCA results in significant upfront costs and a risk of procedural complications. However, the potential quality-of-life benefits through long-term absence of arrhythmia and any associated prognostic benefits (for example, reduced risk of stroke) may outweigh the costs when compared to longterm use of anti-arrhythmic drug (AAD) therapy and its associated adverse effects. Only one prev...

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Section: Methodsmentioning

confidence: 99%

Cost-effectiveness of radiofrequency catheter ablation for the treatment of atrial fibrillation in the United Kingdom

McKenna

Palmer

Rodgers

et al. 2008

Heart

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“…Despite evidence that people in AF are at an increased risk of stroke,3 large randomised controlled studies (including the AFFIRM trial)7 observed rate and rhythm control using drugs to be equivalent in terms of mortality 7 8. This can largely be attributed to the poor efficacy and harmful side effects of antiarrhythmic drugs (AADs) 9.…”

Section: Rate or Rhythm Control?mentioning

confidence: 99%

“…As asymptomatic AF is common, the worse outcome in the rhythm control groups may be attributed to occult AF and ischaemic strokes occurring in patients where anticoagulation had been discontinued 3. A recent study was performed with 2580 participants with either pacemakers or implantable cardiac defibrillators in whom asymptomatic AF burden could be accurately assessed by the device.…”

Section: Rate or Rhythm Control?mentioning

confidence: 99%

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Catheter ablation for atrial fibrillation: who, why and does it work?

Eyre-Brook

Rajappan

2012

Postgraduate Medical Journal

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Atrial fibrillation (AF) is the most common arrhythmia. For many years, treatment was predominantly pharmacological. The identification of signals from the pulmonary veins as critical to AF in many patients led to catheter ablation targeting these signals. Catheter ablation is more effective than antiarrhythmic drugs at restoring sinus rhythm, and may improve mortality, morbidity and quality of life in patients with symptomatic AF. There is evidence to suggest that catheter ablation would be even more beneficial if undertaken earlier in the disease process. Cost effectiveness of catheter ablation remains under assessment, but it does meet the NICE definition of cost efficacy and the figure improves as stroke risk rises. It is true that long-term data are lacking. However, until results of current long-term studies become available, ablation will continue to be reserved predominantly for patients with drug-refractory, symptomatic AF.

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“…36 Even in patients after cardioversion, thromboembolic events occur after the anticoagulation is stopped or is subtherapeutic. 37 Thus, in patients with persistent atrial fibrillation, anticoagulation should be considered long term in those who are at risk of recurrence of atrial fibrillation or in those who have stroke risk factors.…”

Section: Persistent and Paroxsymal Atrial Fibrillationmentioning

confidence: 99%