Cost-Effectiveness of Catheter Ablation for Rhythm Control of Atrial Fibrillation

Objective. The objective of this study is to evaluate the cost-effectiveness of catheter ablation for rhythm control compared to antiarrhythmic drug (AAD) therapy in patients with atrial fibrillation (AF) who have previously failed on an AAD.Methods. An economic model was developed to compare (1) catheter ablation and (2) AAD (amiodarone 200 mg/day). At the end of the initial 12 month phase of the model, patients are classified as being in normal sinus rhythm or with AF, based on data from a meta-analysis. In the 5-year Markov phase of the model, patients are at risk of ischemic stroke each 3-month model cycle.Results. The model estimated that, compared to the AAD strategy, ablation had $8,539 higher costs, 0.033 fewer strokes, and 0.144 more QALYS over the 5-year time horizon. The incremental cost per QALY of ablation compared to AAD was estimated to be $59,194. The probability of ablation being cost-effective for willingness to pay thresholds of $50,000 and $100,000 was estimated to be 0.89 and 0.90, respectively.Conclusion. Based on current evidence, pulmonary vein ablation for treatment of AF is cost-effective if decision makers willingness to pay for a QALY is $59,194 or higher.

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Perioperative Outcomes and Safety of Atrial Fibrillation Catheter Ablation in Octogenarians: A Retrospective Study and Review of the Benefits of Rhythm Control

Cardiology ◽

10.1159/000464403 ◽

2017 ◽

Vol 137 (3) ◽

pp. 173-178

Author(s):

Stephanie Hakimian ◽

Juan C. Camacho ◽

Edwin Grajeda Silvestri ◽

Farid AbdelMalak ◽

Elie Donath ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Normal Sinus Rhythm ◽

Therapeutic Option ◽

Sinus Bradycardia ◽

Age Groups ◽

Coronary Intervention ◽

Rhythm Control ◽

Perioperative Outcomes ◽

Normal Sinus

Objectives: Catheter ablation for rhythm control has emerged as a successful therapeutic option for the treatment of atrial fibrillation (AF), though it has not been well studied in octogenarians. This study evaluates its safety in octogenarians in a community hospital and reviews the benefits of rhythm control. Methods: Among 1,592 patients undergoing AF ablation, 84 octogenarian were identified. The primary outcome was normal sinus rhythm (NSR) on electrocardiogram at discharge. Secondary outcomes were periprocedural complications and markers and risks of reablation compared to younger cohorts. Results: An NSR on discharge occurred in 83 patients. Three patients required pacing for symptomatic sinus bradycardia, complete heart block, and symptomatic junctional bradycardia, respectively. Reablation for recurrent AF occurred in 23 octogenarians. Using the octogenarians as reference, the relative risk (RR) of 1 reablation was not significantly different among the age groups 70-79, 60-69, and <60 years. The RR of 2 reablations was greater in the octogenarian group (RR 0.26 [95% CI 0.09-0.71, p = 0.008], 0.42 [95% CI 0.17-1.04, p = 0.06], and 0.27 [95% CI 0.1-0.75, p = 0.01], respectively). Coronary artery disease (OR 0.14, 95% CI 0.02-0.68, p = 0.026) and percutaneous coronary intervention (OR 0.13, 95% CI 0.02-0.63, p = 0.021) were markers for reablation. Conclusion: AF catheter ablation achieved an NSR with minimal periprocedural complications. The benefits of rhythm control should be considered in treatment.

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Cost-effectiveness of catheter ablation versus medical therapy for the treatment of atrial fibrillation in the United Kingdom

EP Europace ◽

10.1093/europace/euab116.531 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

L Leung ◽

RJ Imhoff ◽

D Frame ◽

PJ Mallow ◽

L Goldstein ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Cost Effectiveness ◽

Catheter Ablation ◽

Medical Therapy ◽

Rhythm Control ◽

Uk National Health Service ◽

The Uk ◽

The Cost ◽

Af Recurrence

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): This research study was funded by Biosense Webster, Inc. Dr Leung has received research support from Attune Medical (Chicago, IL) towards a research fellowship at St. George"s University of London. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Background Randomised data on patient-related outcomes comparing catheter ablation to medical therapy for the treatment of atrial fibrillation (AF) have shown the effectiveness of catheter ablation. Ablation versus medical therapy should also be analysed from a health economics perspective to achieve optimal healthcare resource allocation. Purpose To determine the cost effectiveness of catheter ablation compared to medical therapy for the treatment of atrial fibrillation, from the perspective of the UK National Health Service. Methods A patient-level Markov health-state transition model was used to conduct a cost utility analysis comparing catheter ablation and medical therapy for the treatment of AF. A systematic review and meta-analysis of catheter ablation treatment versus medical therapy (rhythm and/or rate control drugs) was conducted to enable comparison of AF recurrence between treatment groups utilising the model. Additional model parameters were established based upon a best-evidence review of the literature. The model simulated care delivered from a secondary care perspective. Total patients simulated in this model over a lifetime were 250,000, with patients entering the model at age 64. Only previously treated AF patients were included, including those with concomitant heart failure. A separate scenario analysis was conducted to determine the cost effectiveness specifically in the cohort of patients with AF and heart failure. Main outcomes measures Incremental cost-effectiveness ratio (ICER) and average total expected costs and quality-of-life years (QALYs) incurred over the lifetime of a patient. AF recurrence, complications and cardiovascular adverse events were compared over the total duration inside the model. Results In the base case analysis, catheter ablation resulted in a favourable ICER of £8,614 per additional QALY gained when compared to medical therapy, well below the national Willingness-to-Pay threshold of £20,000. Catheter ablation was associated with an expected increase of 1.01 QALYs, while adding an additional cost £8,742 over a patient’s lifetime. The cost-effectiveness of catheter ablation was improved in the heart failure sub-group analysis, with an ICER of £6,438. A significantly greater proportion of patients in the medical therapy group failed rhythm control at any stage compared to catheter ablation (72% vs 24%) and at a faster rate (median time to treatment failure: 3.8 vs 10 years). Conclusion Catheter ablation appears to be a highly cost-effective treatment for atrial fibrillation, compared to medical therapy, from the perspective of the UK National Health Service. With low rates of adverse events and superiority in achieving rhythm control, AF ablation services should be prioritised with appropriate allocation of healthcare resources.

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Flecainide is well-tolerated and effective in patient with atrial fibrillation at 12 months: a retrospective study

Therapeutic Advances in Cardiovascular Disease ◽

10.1177/1753944720926824 ◽

2020 ◽

Vol 14 ◽

pp. 175394472092682

Author(s):

Mikayla Muzzey ◽

Katie B. Tellor ◽

Karthik Ramaswamy ◽

Martin Schwarze ◽

Anastasia L. Armbruster

Keyword(s):

Atrial Fibrillation ◽

Adverse Effects ◽

Control Strategies ◽

Normal Sinus Rhythm ◽

Hot Flashes ◽

Retrospective Chart Review ◽

Structural Heart Disease ◽

Rhythm Control ◽

Normal Sinus ◽

Proven Efficacy

Introduction: Current atrial fibrillation (AF) guidelines recommend flecainide as a first-line rhythm control option in patients without structural heart disease. While there is proven efficacy in clinical trials and guideline support, it is hypothesized that flecainide may be underutilized due to negative outcomes in the CAST trial and that adverse effects are less common than previously perceived. Methods: This retrospective chart review evaluated patients ⩾18 years initiated on flecainide for AF from August 2011 to October 2016 by a cardiology provider at the study site. Exclusion criteria included: <5 days of flecainide therapy, AF due to a reversible cause, and inadequate documentation. The primary outcome was efficacy of flecainide at maintaining symptomatic control at 6 and 12 months. Secondary outcomes included characterization of alterations in rhythm control strategies and documented normal sinus rhythm per electrocardiogram at 6 and 12 months. Results: Of the 326 patients identified, 144 patients were included. After 6 and 12 months, 102 patients (70.8%) and 89 patients (61.8%) of the 144 were symptomatically controlled. Atenolol use ( p = 0.024), female sex ( p = 0.006), hypertension ( p = 0.040), and dronedarone failure ( p = 0.012) were associated with flecainide discontinuation at 6 months. At 12 months, only previous propafenone failure ( p = 0.032) was significant. Of the 144 patients, 16 (11.1%) reported adverse effects with dizziness, hot flashes, bradycardia, and headache (1.4% each) being the most common. Conclusion: Flecainide is a well-tolerated medication, even at 12 months, with very minor adverse effects. These results support the utility of flecainide in guideline recommended patient populations.

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Bucindolol Decreases Atrial Fibrillation Burden in Patients with Heart Failure and the ADRB1 Arg389Arg Genotype

Circulation Arrhythmia and Electrophysiology ◽

10.1161/circep.120.009591 ◽

2021 ◽

Author(s):

Jonathan P. Piccini ◽

Christopher Dufton ◽

Ian A. Carroll ◽

Jeff S. Healey ◽

William T. Abraham ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Sinus Rhythm ◽

Normal Sinus Rhythm ◽

Left Ventricular ◽

Rhythm Control ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Normal Sinus

Background - Bucindolol is a genetically targeted β-blocker/mild vasodilator with the unique pharmacologic properties of sympatholysis and ADRB1 Arg389 receptor inverse agonism. In the GENETIC-AF trial conducted in a genetically defined heart failure (HF) population at high risk for recurrent atrial fibrillation (AF), similar results were observed for bucindolol and metoprolol succinate for the primary endpoint of time to first atrial fibrillation (AF) event; however, AF burden and other rhythm control measures were not analyzed. Methods - The prevalence of ECGs in normal sinus rhythm, AF interventions for rhythm control (cardioversion, ablation and antiarrhythmic drugs), and biomarkers were evaluated in the overall population entering efficacy follow-up (N=257). AF burden was evaluated for 24 weeks in the device substudy (N=67). Results - In 257 patients with HF the mean age was 65.6 ± 10.0 years, 18% were female, mean left ventricular ejection fraction (LVEF) was 36%, and 51% had persistent AF. Cumulative 24-week AF burden was 24.4% (95% CI: 18.5, 30.2) for bucindolol and 36.7% (95% CI: 30.0, 43.5) for metoprolol (33% reduction, p < 0.001). Daily AF burden at the end of follow-up was 15.1% (95% CI: 3.2, 27.0) for bucindolol and 34.7% (95% CI: 17.9, 51.2) for metoprolol (55% reduction, p < 0.001). For the metoprolol and bucindolol respective groups the prevalence of ECGs in normal sinus rhythm was 4.20 and 3.03 events per patient (39% increase in the bucindolol group, p < 0.001), while the rate of AF interventions was 0.56 and 0.82 events per patient (32% reduction for bucindolol, p = 0.011). Reductions in plasma norepinephrine (p = 0.038) and NT-proBNP (p = 0.009) were also observed with bucindolol compared to metoprolol. Conclusions - Compared with metoprolol, bucindolol reduced AF burden, improved maintenance of sinus rhythm, and lowered the need for additional rhythm control interventions in patients with HF and the ADRB1 Arg389Arg genotype.

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Cost-effectiveness of a supplementary class-based exercise program in the treatment of knee osteoarthritis

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462306050872 ◽

2006 ◽

Vol 22 (1) ◽

pp. 84-89 ◽

Cited By ~ 21

Author(s):

Gerry Richardson ◽

Neil Hawkins ◽

Christopher James McCarthy ◽

Pauline Mary Mills ◽

Rachel Pullen ◽

...

Keyword(s):

Cost Effectiveness ◽

Willingness To Pay ◽

Exercise Program ◽

Cost Effective ◽

Quality Adjusted Life Year ◽

Current Evidence ◽

Net Benefit ◽

Unit Costs ◽

Home Based ◽

The Cost

Objectives:The aim of this study was to assess the cost-effectiveness of a class-based exercise program supplementing a home-based program when compared with a home-based program alone. In addition, we estimated the probability that the supplementary class program is cost-effective over a range of values of a decision maker's willingness to pay for an additional quality-adjusted life-year (QALY).Methods:The resource use and effectiveness data were collected as part of the clinical trial detailed elsewhere. Unit costs were estimated from published sources. The net benefit approach to cost-effectiveness analysis is used to estimate the probability of the intervention being cost-effective.Results:The addition of a supplementary class-based group results in an increase in QALYs and lower costs. For all plausible values of a decision maker's willingness to pay for a QALY, the supplementary class group is likely to be cost-effective.Conclusions:The addition of a class-based exercise program is likely to be cost-effective and, on current evidence, should be implemented.

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Ranolazine as you have never seen it before: an antiarrhythmic for atrial fibrillation

European Heart Journal ◽

10.1093/ehjci/ehaa946.0555 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J.P Sousa ◽

L Puga ◽

J Ribeiro ◽

J Lopes ◽

C Saleiro ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cohort Studies ◽

Meta Analysis ◽

Rhythm Control ◽

Current Evidence ◽

Qtc Interval ◽

Interval Prolongation ◽

Qtc Interval Prolongation ◽

Secondary Endpoints

Abstract Background Currently available pharmacological options for rhythm control in atrial fibrillation (AF) are overshadowed by suboptimal efficacy and both frequent and potentially severe adverse events. Recent studies have added evidence to the hypothesis that ranolazine might exert antiarrhythmic effects, particularly in atrial tachyarrhythmias. Purpose To perform a systematic review with meta-analysis in order to ascertain the potential role of ranolazine in the management of AF. Methods We systematically searched MEDLINE, Embase and Scopus for randomized controlled trials (RCTs) and cohort studies addressing the association between ranolazine and AF outcomes, published up until December 1, 2019. The primary endpoint was incidence of AF, which was evaluated under a ranolazine versus placebo design. In this regard, patients in the setting of postcardiac surgery were further investigated separately. Secondary endpoints included AF cardioversion outcomes, which were addressed through comparison between ranolazine plus amiodarone and amiodarone alone for proportional efficacy and temporal requirements (time-to-cardioversion). The latter analysis was also undertaken in a dose-sensitive fashion (≤1000mg vs. 1500mg of ranolazine). Tertiary endpoints covered AF burden and episodes, in paroxysmal AF patients, and safety outcomes, namely death, QTc interval prolongation and hypotension. Study-specific odds ratios (ORs) were pooled using meta-analytic techniques with a random-effects model. Results A total of 10 RCTs comprising 8.109 participants and 3 cohort studies encompassing 37.112 patients were regarded as eligible for evaluation. Ranolazine was found to attenuate patients' odds of developing AF (OR 0.53, 95% CI: 0.41–0.69, p<0.001, i2=58%). This effect held true, with an even larger effect size, in the context of post-cardiac surgery (OR 0.34, 95% CI: 0.16–0.72, p=0.005, i2=64%). Ranolazine increased the chances of successful AF cardioversion when added to amiodarone over amiodarone alone (OR 6.67, 95% CI: 1.49–29.89, p=0.01, i2=76%), while significantly reducing time-to-cardioversion [SMD 9.54h, 95% CI: −13.3–5.75, p<0.001, i2=99%]. Interestingly, cardioversion was faster with ≤1000mg of ranolazine (SMD −13.16h, 95% CI: −15.07–11.25, p<0.001, i2=95%) than with 1500mg (SMD −3.57h, 95% CI: −5.06–2.08, p<0.001, i2=23%). In paroxysmal AF, ranolazine was also proved to significantly reduce both AF burden and episodes. There were no safety signals regarding mortality odds, QTc interval prolongation (mostly clinically insignificant) and hypotension (mostly transitory). Conclusion Current evidence suggests that ranolazine provides an effective and safe option for a chemical rhythm control strategy in AF management, a field in which medical breakthroughs are desperately needed. Funding Acknowledgement Type of funding source: None

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Economic evaluation of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) for stroke prevention in patients with atrial fibrillation: a systematic review and meta-analysis

BMJ evidence-based medicine ◽

10.1136/bmjebm-2020-111634 ◽

2021 ◽

pp. bmjebm-2020-111634

Author(s):

Rini Noviyani ◽

Sitaporn Youngkong ◽

Surakit Nathisuwan ◽

Bhavani Shankara Bagepally ◽

Usa Chaikledkaew ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Economic Evaluation ◽

Cost Effectiveness ◽

Meta Analysis ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Cost Effective ◽

Risk Of Bias

ObjectivesTo assess cost-effectiveness of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF) by pooling incremental net benefits (INBs).DesignSystematic review and meta-analysis.SettingWe searched PubMed, Scopus and Centre for Evaluation of Value and Risks in Health Registry from inception to December 2019.ParticipantsPatients with AF.Main outcome measuresThe INB was defined as a difference of incremental effectiveness multiplied by willing to pay threshold minus the incremental cost; a positive INB indicated favour treatment. These INBs were pooled (stratified by level of country income, perspective, time-horizon, model types) with a random-effects model if heterogeneity existed, otherwise a fixed effects model was applied. Heterogeneity was assessed using Q test and I2 statistic. Risk of bias was assessed using the economic evaluations bias (ECOBIAS) checklist.ResultsA total of 100 eligible economic evaluation studies (224 comparisons) were included. For high-income countries (HICs) from a third-party payer (TPP) perspective, the pooled INBs for DOAC versus VKA pairs were significantly cost-effective with INBs (95% CI) of $6632 ($2961.67 to $10 303.72; I2=59.9%), $6353.24 ($4076.03 to $8630.45; I2=0%), $7664.58 ($2979.79 to $12 349.37; I2=0%) and $8573.07 ($1877.05 to $15 269.09; I2=0%) for dabigatran, apixaban, rivaroxaban and edoxaban relative to VKA, respectively but only dabigatran was significantly cost-effective from societal perspective (SP) with an INB of $11 746.96 ($2429.34 to $21 064.59; I2=52.4%). The pooled INBs of all comparisons for upper-middle income countries (UMICs) were not significantly cost-effective. The ECOBIAS checklist indicated that risk of bias was mostly low for most items with the exception of five items which should be less influenced on pooling INBs.ConclusionsOur meta-analysis provides comprehensive economic evidence that allows policy makers to generalise cost-effectiveness data to their local context. All DOACs may be cost-effective compared with VKA in HICs with TPP perspective. The pooling results produced moderate to high heterogeneity particularly in UMICs. Further studies are required to inform UMICs with SP.PROSPERO registeration numberCRD 42019146610.

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TO DETERMINE THE ROLE OF RANOLAZINE FOR RHYTHM CONTROL STRATEGY IN PATIENTS WITH NON- VALVULAR ATRIAL FIBRILLATION- AN OBSERVATIONAL STUDY FROM A TERTIARY CARE CENTER. (RANOVA STUDY)

10.36106/gjra/9601756 ◽

2020 ◽

pp. 48-53

Author(s):

Praveen Shukla ◽

Awadhesh Kumar Sharma ◽

Biswajit Majumder ◽

Pritam Kumar Chatterjee ◽

Vinay Krishna ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Control Strategy ◽

Normal Sinus Rhythm ◽

Rhythm Control ◽

Normal Sinus ◽

History Of ◽

Group A ◽

Group B

Objectives – Non- valvular atrial fibrillation (NVAF) is the most commonly occurring arrhythmia worldwide .Ranolazine is an emerging drug with a ray of hope in the management of NVAF. This is the first large observational study with longer follow up of one year. Methods - It is a hospital based observational prospective study. A total of 100 patients was recruited for the study .The primary objective was to determine the efficacy of ranolazine in converting NVAF to sinus rhythm & the secondary objective was to study epidemiological aspects of NVAF. Results –After 1 month of follow up conversion to normal sinus rhythm was 12% in group A & 6% in group B (6%), it was not significant statistically (Z=1.48p=0.13). After 6 months, conversion to normal sinus rhythm was increased from 12% to 18% in group A which was preserved at 12 months of follow up and statistically significant and higher than that of group B (6.0%) (Z=2.61p=0.009). In predisposing risk factors & other co-morbidities HTN was present in 61%, obesity together with overweight in 37%, smoking in 44%, history of moderate amount of alcohol intake in 35%, history of CVA/TIA in 13%, DM in 11%, CKD in 4%, CAD in 30%, COPD in 20% and congestive heart failure in 15% of the patients. Conclusion- Ranolazine is an effective option when used for rhythm control strategy in NVAF. HTN is the predominant predisposing risk factor.

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Characterization of Pulmonary Vein Dimensions Using High-Definition 64-Slice Computed Tomography prior to Radiofrequency Catheter Ablation for Atrial Fibrillation

Cardiology Research and Practice ◽

10.1155/2014/179632 ◽

2014 ◽

Vol 2014 ◽

pp. 1-8 ◽

Cited By ~ 11

Author(s):

Catherine Gebhard ◽

Nazmi Krasniqi ◽

Barbara E. Stähli ◽

Bernd Klaeser ◽

Tobias A. Fuchs ◽

...

Keyword(s):

Computed Tomography ◽

Atrial Fibrillation ◽

Catheter Ablation ◽

Pulmonary Vein ◽

Radiofrequency Catheter Ablation ◽

Normal Sinus Rhythm ◽

Normal Subjects ◽

High Definition ◽

Normal Sinus ◽

The Difference

Background. Contrast-enhanced computed tomography is commonly acquired before radiofrequency catheter ablation (RFCA) for atrial fibrillation (AFib) to guide the procedure. We analyzed pulmonary vein (PV) ostial diameter and volumes on a high-definition 64-slice CT (HDCT) scanner in patients with AFib prior to RFCA.Methods and Results. This retrospective study included 50 patients (mean age 60.2 ± 11.4 years, 30 males) undergoing cardiac HDCT scanning before RFCA for drug refractory AFib and 50 age-, BMI-, and sex-matched controls with normal sinus rhythm undergoing HDCT. PV ostial diameter and volume were measured and calculated using a semiautomatic calliper tool. Total ostial PV volume was significantly increased in patients with AFib as compared to controls (P<0.005). Similarly, total ostial PV diameter was significantly increased in AFib compared to controls (P<0.001). In AFib, the largest PV volume and diameters were measured in right superior PV (P<0.05versus controls). The difference in PV volume between patients and controls was most pronounced in right superior PVs (P=0.015). Right middle PVs were found more often in patients with AFib (16/50; 32%) than in normal subjects (7/50; 14%).Conclusion. Enlargement of PV ostial area and enlargement of volume are frequent findings in patients with drug refractory AFib. These parameters may add to the risk stratification for AFib recurrence following RFCA.

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