Most diseases have a turning point, a time when things begin to change.
What follows is a report on what I believe may be (pardon the big word) an inflection point in the way we think about the most common heart-rhythm disorder.
Dr Rajeev Pathak, an electrophysiology fellow in the laboratory of Prof Prashanthan Sanders in Adelaide, Australia, gave the presentation. It happened late in the afternoon, in a small room, nestled into a back corner of the massive convention hall. Even though this paper won the prestigious Eric Prystowsky award for outstanding clinical science, there were no press releases, no simultaneous publications, and nearly no attendees in the small room. Session chair Dr Francis Marchlinski (University of Pennsylvania, Philadelphia) remarked that it "was too bad more people weren't here to hear this."
Here's my recap of the Aggressive Risk Factor Reduction Study-Implications for Ablation Outcomes (ARREST-AF) trial:
Background: Previous work from the Adelaide researchers has demonstrated the causative role of typical cardiovascular risk factors (obesity, high blood pressure, diabetes, smoking, alcohol, sleep apnea, etc) in promoting the substrate for atrial fibrillation. Last year at the Heart Rhythm Society 2013 Scientific Sessions, this group presented data showing that weight loss (in obese sheep) resulted in favorable structural and electrical properties of the atria. Most notably, there was a reduction in interstitial fibrosis.
They then demonstrated similar findings in humans. In this study, which was published in the Journal of the American Medical Association, they selected overweight AF patients on the waiting list for ablation and randomized them to either a physician-led lifestyle-intervention group or standard care. Both groups lost weight and improved on measures of overall health, but those in the aggressive-intervention group improved much more. Just like the sheep, humans who lost weight enjoyed shrinking LA volumes and striking drops in AF burden, with 30% of patients avoiding AF ablation altogether.
This work set the stage for ARREST-AF. Dr Sanders told me they figured if risk-factor modification worked before ablation, it would likely work after. The hypothesis, therefore, was that late recurrence of AF after ablation is due to progression of the underlying substrate, and aggressive risk-factor intervention would improve ablation outcomes.
Methods: Patients (n=165) were selected for the study after their first AF ablation if they had a body-mass index (BMI) >27 and one risk factor, such as hypertension, diabetes, sleep apnea, or abnormal lipids. All patients were offered aggressive risk-factor management in a physician-led clinic. The active-treatment group included 61 patients who accepted, while the 88 patients who refused made up the control group. The two groups were followed for two years, and the primary outcome measure was recurrence of AF.
Patients in the active-treatment group underwent intense lifestyle modification, which included active weight-management strategies and medical treatment of hyperlipidemia, glucose intolerance, high blood pressure, and sleep apnea. Tobacco and alcohol use were aggressively targeted. These primary therapies were accomplished in a separate clinic from electrophysiology. Dr Sanders emphasized that the Adelaide brand of risk-factor modification is unique and robust.
Results: The impact on risk factors was striking. Patients in the risk-factor-modification arm lost weight. Glycemic control improved, blood pressure dropped, and the percent of patients with nocturnal hypoxic episodes decreased.
Structural changes of the heart also were significant. Left atrial volume and LV diastolic volume decreased. Using standard questionnaires, measures of AF symptom burden and global well-being also improved.
AF-free survival after a single ablation procedure was 62% for patients in risk-factor-modification group and 26% for the control arm. After multiple ablations, AF-free survival increased to 87% in the risk-factor-modification group vs 48% in the control arm. Said another way, Adelaide-style risk-factor management increased the success rate of AF ablation fivefold.
Conclusion: Risk-factor management improves outcomes after AF ablation and should be considered crucial when choosing a rhythm-control strategy.
I'm going to do something unusual. Rather than offer opinion, I'll present words from Dr John Day (Intermountain Health, Salt Lake City UT), who is president-elect of the Heart Rhythm Society and program director of this meeting.
During a session entitled "How to prevent and reverse AF," Dr Day gave one of the most unusual talks I have ever heard at a medical meeting. He started with a personal confession:
"U ntil a few years ago, my life was about ablating AF, thousands of ablations, three per day. In the process of this, I didn't give a whole lot of thought as to how the patient got AF or what was happening to my life."
I was now hooked, utterly mesmerized. I thought to myself: is this really happening, or am I jetlagged?
Next, as he showed images of his diet at the time—doughnuts, pizza, and soda—he told the audience:
"At age 44, my health had hit rock bottom. I was overweight. I had developed high blood pressure, high cholesterol, palpitations, insomnia, and even an autoimmune disease. And I was taking five medications. Something had to change."
Stay with me. It gets better.
He described trying the usual diets and solutions, even the "gluten-free thing." Not much happened. Then he got interested in the famous book The China Study .
"I became fascinated with some of these rural Chinese villages where people lived long lives, free of heart disease and cancer. I speak Chinese, and we visited these places multiple times.
What I learned has taken my life in a whole new direction.
My entire perspective of AF has changed from one of ablation to one of . . . does AF even need to happen?"
Let me remind you that Dr Day is about to lead the world's most influential electrophysiology society.
Then he showed an incredibly professional four-minute video of a Chinese village. (He's writing a book, and this is likely the trailer.) Alongside rolling streams were smiling 100-year-old Chinese women. A calm female voice narrates . . .
"T hey have such a sense of peace about them."
Then this, in Dr Day's voice:
"W hether you are 40, or 50, or 60, or 70, it's never too late to make changes."
The video stops, but Dr Day continues:
"I began to slow down. I started looking at the big picture, eating real food, sleeping. My extra weight came off without trying; my cholesterol fell nearly 100 points; my BP dropped 30 to 40 points and my CRP went below 1.
"I now take no medications. I feel good."
And for the win:
"T his has changed my approach when I meet with patients. No longer is atrial fibrillation something that we just ablate."
In an interview with me the next day, Dr Day said he thinks (in most cases) AF may be unnecessary.
Cite this: Is Atrial Fibrillation Necessary? The Most Important Study Presented at the Heart Rhythm Society 2014 Scientific Sessions - Medscape - May 11, 2014.