Dataset Information

Meta-analysis of randomized controlled trials on atrial fibrillation ablation in patients with heart failure with reduced ejection fraction.

ABSTRACT:

Background

The role of catheter ablation (CA) is increasingly recognized as a reasonable therapeutic option in patients with atrial fibrillation (AF) and heart failure (HF).

Hypothesis

We aimed to compare CA to medical therapy in AF patients with HF with reduced ejection fraction (HFrEF).

Methods

We searched the literature for randomized clinical trials comparing CA to medical therapy in this population.

Results

Six trials with a total of 775 patients were included. AF was persistent in 95% of patients with a mean duration of 18.5 ± 23 months prior enrollment. The mean age was 62.2 ± 7.8 years, mostly males (83%) with mean left ventricular ejection fraction (LVEF) of 31.2 ± 6.7%. Compared to medical therapy, CA has significantly improved LVEF by 5.9% (Mean difference [MD] 5.93, confidence interval [CI] 3.59-8.27, P < 0.00001, I² = 87%), quality of life, (MD -9.01, CI -15.56, -2.45, P = 0.007, I² = 47%), and functional capacity (MD 25.82, CI 5.46-46.18, P = 0.01, I² = 90%). CA has less HF hospital readmissions (odds ratio [OR] 0.5, CI 0.32-0.78, P = 0.002, I² = 0%) and death from any cause (OR 0.46, CI 0.29-0.73, P = 0.0009, I² = 0%). Freedom from AF during follow-up was higher in patients who had CA (OR 24.2, CI 6.94-84.41, P < 0.00001, I² = 81%.

Conclusion

CA was superior to medical therapy in patients with AF and HFrEF in terms of symptoms, hemodynamic response, and clinical outcomes by reducing AF burden. However, these findings are applicable to the very specific patients enrolled in these trials.

SUBMITTER: Smer A

PROVIDER: S-EPMC6489934 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundRandomized clinical trials have demonstrated that catheter ablation for atrial fibrillation in patients with heart failure with reduced ejection fraction may improve survival and other cardiovascular outcomes.MethodsWe constructed a decision-analytic Markov model to estimate the costs and benefits of catheter ablation and medical management in patients with symptomatic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) and atrial fibrillation over a lifetime horizon. Evidence from the published literature informed the model inputs, including clinical effectiveness data from meta-analyses. Probabilistic and deterministic sensitivity analyses were performed. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective.ResultsCatheter ablation was associated with 6.47 (95% CI, 5.89-6.93) quality-adjusted life years (QALYs) and a total cost of $105 657 (95% CI, $55 311-$191 934; 2018 US dollars), compared with 5.30 (95% CI, 5.20-5.39) QALYs and $63 040 (95% CI, $37 624-$102 260) for medical management. The incremental cost-effectiveness ratio for catheter ablation compared with medical management was $38 496 (95% CI, $5583-$117 510) per QALY gained. Model inputs with the greatest variation on incremental cost-effectiveness ratio estimates were the cost of ablation and the effect of catheter ablation on mortality reduction. When assuming a more conservative estimate of the treatment effect of catheter ablation on mortality (hazard ratio of 0.86), the estimated incremental cost-effectiveness ratio was $74 403 per QALY gained. At a willingness-to-pay threshold of $100 000 per QALY gained, atrial fibrillation ablation was found to be economically favorable compared with medical management in 95% of simulations.ConclusionsCatheter ablation in patients with heart failure with reduced ejection fraction patients and atrial fibrillation may be considered economically attractive at current benchmarks for societal willingness-to-pay in the United States.