Conference Coverage

CABANA: AF ablation ties drug management, with an asterisk for crossovers

Publish date: May 11, 2018

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Catheter ablation looks at least as good as drugs

The data from CABANA suggest that at the least, catheter ablation is the equivalent of drug therapy, and I think in many cases, it is probably superior. Patients with atrial fibrillation should be allowed to undergo ablation as their first treatment, performed by operators who know what they’re doing. These are excellent results, but they do not apply to every patient with atrial fibrillation; they apply to patients like those enrolled in the trial.

Dr. Eric N. Prystowsky Mitchel L. Zoler/MDedge News

Dr. Eric N. Prystowsky

Some people will look at the results from the intention-to-treat analysis of the primary endpoint and say that this is a neutral result. The patients who I treat often ask me “if I get this treatment, what will likely happen to me.” They are not interested in what happened to patients in a trial who never received the treatment they were supposed to get. I recommend that people interested in CABANA, look at the full data set and do not limit themselves to a knee-jerk reaction to the intention-to-treat analysis.

The results also speak very loudly about the importance of sinus rhythm in patients with heart failure. The results in the subgroup of patients with heart failure appear to support the findings from CASTLE-AF (N Engl J Med. 2018 Feb 1;378[5]:417-27).

Eric N. Prystowsky, MD , is a cardiac electrophysiologist with the St. Vincent Medical Group in Indianapolis. He has been a consultant to CardioNet and Medtronic, has an equity interest in Stereotaxis, and receives fellowship support from Medtronic and St. Jude. He made these comments as designated discussant for CABANA.


 

REPORTING FROM HEART RHYTHM 2018


The dilemma that Dr. Ruskin and other physicians who heard the results voiced was how best to interpret the study’s primary results.

“This trial was designed to address whether ablation has an impact [compared with medical management] on hard endpoints, like mortality, and the intention-to-treat analysis showed no difference. I feel bound to adhere to the intention-to-treat analysis, the primary result” the traditional default arbiter of a randomized trial’s outcome, Dr. Ruskin said in an interview, “But intention-to-treat analyses are built on a foundation where most patients are maintained on their assigned treatment.”

Dr. Christine M. Albert Mitchel L. Zoler/MDedge News

Dr. Christine M. Albert

“As a practicing physician, I’ll look at the on-treatment analysis because those are the patients who actually got the treatment,” commented Christine M. Albert, MD, professor of medicine at Harvard and director of the Center for Arrhythmia Prevention at Brigham and Women’s Hospital, Boston. She also highlighted a clear message from the trial about ablation.

The results “tell us that there wasn’t harm from ablation,” Dr. Albert said during a press conference. “That is really important because, before this, we didn’t know for sure. These data make me a little more confident about offering patients ablation. I now have data to discuss with patients that’s useful for decision making.”

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