Concerns Over Plans to Limit Atrial Fibrillation Ablation

Peter Russell

January 27, 2020

Concerns have been raised about NHS proposals to limit commissioning for atrial fibrillation ablation.

A consultant cardiologist told Medscape News UK that planned changes could lead to patients having to wait longer for treatment, while people from more socially deprived backgrounds could miss out.

NHS England (NHSE) produced plans for a wide-ranging set of criteria to be fulfilled prior to patients being eligible for catheter ablation for paroxysmal and persistent atrial fibrillation (AF).

The document supported the use of catheter ablation for reducing symptoms of AF, but said that NHS guidance was lacking over which patients would obtain the most benefit from an ablation, which patients would not benefit, or how many times the procedure should be repeated if symptoms returned.

Stakeholders had until last week to comment.

New Patient Criteria

Among the proposals:

  • No patient would be able to undergo more than one 'redo' procedure without review carried out by experts external to the organisation

  • Ablation for persistent AF would only be offered if the patient had a successful DC cardioversion (DCCV) beforehand, and had been tried on rate control with at least two rate control drugs for at least 3 months

  • Ablation for long standing persistent AF of more than 2 years standing would no longer be possible

  • Ablation for paroxysmal or persistent AF will not be allowed for patients with a body mass index (BMI) of more than 40

  • Patients with a BMI of 35 to 40 would need to demonstrate a documented weight loss of at least 10% of their body weight before they are offered AF ablation

Health Inequalities

Responding to the NHSE proposals, Prof Dhiraj Gupta, a consultant cardiologist and electrophysiologist at the Liverpool Heart and Chest Hospital, warned that the policies could result in a significant group of patients being denied treatment, despite evidence showing they could benefit.

"Whilst the policy has been devised as an attempt to standardise criteria for AF ablation, we fear that it may intensify the inequalities in health access that already exist," he said. "For instance, we know that patients in disadvantaged communities are already less likely to access health care, and these areas suffer from proportionately higher rates of obesity too."

A requirement for patients to have undergone a DCCV before treatment risked lengthening waiting times, according to Prof Gupta, who is also honorary professor of cardiology at the University of Liverpool.

Also controversial was the requirement that a patient should have a minimum trial of drug therapy 3 months after a DCCV with a combination of at least two drugs.

Prof Gupta said he was concerned that this would undermine the importance of speedy treatment, which is linked to successful outcomes.

"Our concern is that by adding this unnecessary step of having to wait for at least 3 months, the reality of the NHS is that if you're only seeing the patient every 2 or 3 months anyway, this is going to add about 6 months to the whole process," he said.

A proposal to require an external review in cases where a patient needed a re-do procedure had "the possibility of introducing unacceptable delays and uncertainty for patients, thereby worsening their clinical condition", according to Prof Gupta, who said it was unclear whether the reviews would be carried out by already busy consultants "who don't have the time to review other hospitals' patients' notes", or by GPs, or health service managers.

Prof Gupta called for a peer review to be carried out inside the same organisation, which should be conducted only by medical personnel who were involved in the day-to-day management of patients with AF.

AF is the most common cardiac arrhythmia, with an estimated prevalence of 3% in persons over 20 years old. Approximately 1.4 million people in England have AF.

Data suggest that AF ablation rates in the UK already lag behind those in other countries in Western Europe.

In his submission, Prof Gupta warned that the "severe restrictions" proposed by the NHSE policies "will only worsen the situation", while also exaggerating existing regional inequalities.

No comment was available from NHSE.

Editor's Note, 29th January 2020: This article was updated for clarity.

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