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Radiofrequency Ablation as Good as Drugs to Treat Atrial Fibrillation

MD-FM Thursday October 25th, 2012





GENERIQUE
Carillon
 
Sarah :
MD FM — Medical News from around the the world with Peter Goodwin

P1
PETER: Hello, and to begin with: new findings report that, in younger and otherwise healthy patients with paroxysmal atrial fibrillation, radiofrequency ablation did as well as antiarrhythmic drug treatments first line --and maybe even better... Sarah?

SARAH: Yes: researchers found no significant differences between the 2 treatment strategies concerning the cumulative burden of AFib during the 2 years following treatment initiation. They measured this cumulative burden using 7-day-holter monitoring at 3, 6, 12, 18 and 24 months. During this last recording though, the percentage of AFib was significantly lower in patients in the ablation group than in those who on drug-therapy.

PETER: So… that means the greater benefit of ablation began to emerge at 2 years?

SARAH: Well, Jen Cosedis Nielsen, first author of the NEJM study, did not want to go that far:

Bob-Nielsen: “I would say that the cumulative is the most important and that the main result of this study is that both these treatments reduces significantly atrial fibrillation”

SARAH: This Dr. Nielsen, from Aarhus University Hospital in Copenhagen, who pointed out that these results were obtained in a population no more than 70 years old but that in practice, the majority of AFib patients are well over 70, and often have comorbidities –so these results cannot be extrapolated to everyone. They are valid for a younger and healthy patient population. Here are his advice for daily practice:

Bob-Nielsen: “The majority of patients will still try drugs first because there are some risks associated also with the ablation procedure: in very rare cases stroke, you can get blood in the pericardium around the heart, so it is rare but it can occur. I would inform patients about the two treatments, about the advantages and disadvantages, I would let the patients participate in the decision on what treatment they should undergo.”

SARAH: Again, that was Dr. Nielsen, from Copenhagen.


VIRGULE MUSICALE

P2
PETER: Smoking, hypertension, high cholesterol, and type-2-diabetes are important risk factors for peripheral arterial disease and and the extent to which they are jointly associated with the incidence of PAD are now well established.:

SARAH: Yes, and depending on how many of these factors patients accumulate, their risk gradually goes up: A study showed that patients with 1 factor had 2.5 more risks of PAD than patients without any factor. Patients with 2 factors had 5 times more risks. 3 factors –10 times more risks. and for the unlucky folks accumulating all 4 factors: a 20 times increased risk of PAD... Listen to Michel Joosten, lead author of the study, give us some of the specifics of his findings:

Bob-Joosten: “What we saw what that the longer you had diabetes or hypercholesterolemia, the higher the risk became of developing PAD. Whereas for hypertension we did not see this –there was no association with time. Whereas for smoking, we also saw strong graded dose response in relation with the amount of cigarettes you smoked. And also for former smokers, we saw that men even after twenty years of smoking cessation, they still had an increased risk of developing PAD, which is quite astonishing I think.”

SARAH: That was Dr. Joosten, of Harvard Medical School in Boston, whose team followed nearly 45,000 men for more than 2 decades. He concluded that, in practice, preventing these factors could help avoid a substantial proportion of PAD cases since, taken together, they accounted for 2/3rd of all PAD cases in the study.


P3
PETER: Transcatheter aortic valve-in-valve implantation is effective in most patients with previous degenerated bioprosthetic valves, according to a study in Circulation. In 200 patients who underwent a second implant, all-cause mortality was 8.4% at 30 days post-procedure. Adverse outcomes included device malposition, ostial coronary obstruction, and post-procedure high gradients. 1-year follow-up was obtained in 43% of patients, with 85.8% survival.

VIRGULE MUSICALE
 
P4
PETER: New data confirm that immediate postoperative irradiation helps prevent recurrences in high-risk prostate cancer patients.

SARAH: Yes: overall, the 10-year data showed that, compared to a wait-and-see approach, immediate postoperative irradiation improved biochemical progression-free survival AND local control, without increasing toxicity. HOWEVER, clinical progression-free survival was NOT improved, neither was overall survival.

Bob-Bolla: “Even though there is no benefit in overall survival, when you have been treated, what you want is to have a good and enjoyable life without relapse. The improvement of local control, the improvement in disease free survival is nevertheless a benefit for the patient.”

PETER: That was lead author of The Lancet study, Pr. Michel Bolla, from Grenoble in France. Further subgroup analyses showed that patients with positive margins and those younger than 70 years old were most likely to benefit most from immediate post-surgery radiation. In patients over 70, overall survival was actually worse…

SARAH: So, Does that mean patients over 70 should avoid this approach?

PETER: Well, Pr. Bolla insisted that the interpretation should not be so radical. In practice, chemotherapy techniques have improved, each case must be discussed on an individual basis, between practitioners from all specialties involved, wheighing the pros and cons of each approach, and considering the patient’s medical history, his quality of life and his desires.


VIRGULE MUSICALE

P5
PETER: Children are particularly vulnerable to traffic pollution during their first year of life…

SARAH: Yes, a study led on more than 2000 children showed that exposure to pollutants during the first year of life led to diminished lung function at 8 years old.

Bob-Pershagen-1: “The overall average lung function deficit was only marginal, but then we had some children with markedly decreased lung function –more than 20%, and the risk of having this more than 20% decrease in lung function was 4 times increased if you were highly exposed to particles from road traffic”

SARAH: That was Pr. Goran Pershagen, from the Karolinska Institute in Sweden, co-author of the study in the American Journal of Respiratory and Critical Care Medicine. He said exposure later in life did not seem to affects the lungs as much…

Bob-Pershagen-2: “We know that the lungs are developing throughout childhood and maybe early effects on this lung development are particularly prominent during the first year.”

SARAH: Pr. Pershagen added that children sensitive to food allergies or airborne allergens, those with asthma, and boys appeared particularly sensitive to pollution. His team is now following these kids up to age 16 to see if the deleterious effects last on into adulthood.



BREVE 1 Sur fond musical
 
PETER: Finally, in brief: new findings in the American Journal of Psychiatry report poorer antidepressant outcomes in patients with major depressive disorder also taking nonsteroidal anti-inflammatory drugs. These findings, in a cohort of over 1,500 outpatients, confirm previous results from the STAR-D study. However, the authors note, some of the effects they observed could result from a confounding factor...

And …..

BREVE 2

PETER: High doses of inhaled corticosteroids could be an independent risk factor for adrenal insufficiency. This is according to findings of a nested case-control study published in the European Respiratory Journal, including 392 patients with adrenal insufficiency. The authors conclude that physicians prescribing high doses of inhaled corticosteroids should thus be sensitive to  symptoms of adrenal insufficiency in their patients.

That's all from MDFM for now. We'll be back next week
 
JINGLE FIN     
 

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