Congress Review | Editors Choice | AHA 2024
Ablation vs Antiarrhythmic Drugs for Ventricular Tachycardia: Insights from AHA Scientific Session 2024
Time to read: 03:58
Time to listen: 06:46
Published on MedED: 25 November 2024
Originally Published: 16 November 2024
Sourced: AHA Scientific Sessions 2024, NEJM
Type of article: In Brief
MedED Catalogue Reference: MCABC002
Category: Cardiovascular Disease
Cross Reference: Neurology
Keywords: Cardiac ablation, arrhythmias, ventricular tachycardia, CAD
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Presented at AHA Scientific Sessions 2024 and published in NEJM 16 November 2024...This summary does not represent the original research, nor is it intended to replace the original research. Content Disclaimer
Ventricular tachycardia (VT) is a leading cause of sudden cardiac death, primarily associated with coronary artery disease (CAD), which is implicated in approximately 80% of cases. Fatal arrhythmias in these patients stem from two mechanisms: acute coronary ischemia (leading to polymorphic VT) and ischemic cardiomyopathy with myocardial scarring (causing monomorphic VT). Left untreated, these arrhythmias often progress to ventricular fibrillation, with catastrophic outcomes.1
Historically, implantable cardioverter-defibrillators (ICDs) have played a central role in reducing sudden cardiac death by terminating VT episodes and preventing arrhythmic death. However, ICDs do not prevent the occurrence of VT, and the shocks they deliver can be distressing for patients. Antiarrhythmic drug therapy, including agents like sotalol and amiodarone, has been used to reduce recurrent VT. Still, their effectiveness is often limited by incomplete suppression of arrhythmias and significant side effects, such as pulmonary toxicity with amiodarone.1
Early studies suggested catheter ablation as an emerging treatment option for VT.
Two landmark randomised clinical trials showed that ablation could significantly reduce VT recurrence following initial drug therapy failure. However, these trials did not directly compare ablation to first-line antiarrhythmic drug therapy. In 2016, the VANISH 1 study demonstrated that catheter ablation was superior to escalating drug therapy for patients with drug-refractory VT, particularly among those experiencing breakthrough VT despite amiodarone. Despite these findings, catheter ablation has typically been reserved as a last-resort therapy after the failure of drug therapy.
Study Hypothesis
This trial hypothesised that catheter ablation would outperform antiarrhythmic drug therapy in reducing death, ICD shocks, VT storms, or treated sustained VT in patients with prior myocardial infarction and sustained monomorphic VT.
Participants
The study included 416 adults with an average age of 68 years at enrollment; 94% of participants were men.
All participants had survived a heart attack, on average, 14 years prior to the study and had an implantable cardioverter defibrillator (ICD).
None of the participants had conditions preventing them from receiving the study medications or undergoing the ablation procedure.
Participants were recruited from 18 centres in Canada, two in the U.S., and two in France.
Study Design
The multicenter, randomised clinical trial trial randomly assigned 416 patients with prior myocardial infarction and clinically significant VT to receive either antiarrhythmic drug therapy (sotalol or amiodarone) or catheter ablation.
Catheter ablation was performed within 14 days after randomization; sotalol or amiodarone was administered as antiarrhythmic drug therapy according to prespecified criteria.
The primary endpoint was a composite of death from any cause, VT storm, ICD shock, or sustained VT requiring intervention after 14 days.
Secondary outcomes included all-cause mortality, hospital admissions for cardiac causes, and adverse effects of treatments.
Results
Over a median follow-up of 4.3 years:
A primary endpoint event occurred in 50.7% of patients in the ablation group versus 60.6% in the drug therapy group (hazard ratio, 0.75; 95% CI, 0.58–0.97; P=0.03).
Among the ablation group, adverse events within 30 days included:
Death in 2 patients (1.0%).
Nonfatal complications in 11.3%.
In the drug therapy group, adverse events attributed to antiarrhythmic treatment included:
Death from pulmonary toxic effects in 1 patient (0.5%).
Nonfatal adverse events in 21.6%.
Study Implications
The findings of this research build on prior research highlighting the limitations of drug therapy for ventricular tachycardia (VT) suppression, offering robust evidence that catheter ablation is a viable first-line treatment option. Unlike earlier studies, this trial directly evaluated the efficacy of ablation as an initial approach and confirmed its significant ability to reduce VT-related events compared to drug therapy alone.
However, the procedural risks associated with ablation underscore the importance of careful patient selection, positioning ablation as an alternative to the traditional reliance on antiarrhythmic medications for patients with sustained VT.
Interviewed in AHA Newsroom, Dr John Sapp, lead author and professor of medicine at Dalhousie University, commented:
“We have previously shown that when medication is not preventing episodes of VT, ablation has led to better outcomes than increasing the medications. Now we know that ablation is a reasonable option for first-line treatment instead of starting with antiarrhythmic medication therapy. We hope that our data will be useful for clinicians and patients deciding on the best treatment to suppress recurrent VT and prevent ICD shocks."
Conclusion
The trial demonstrated that catheter ablation could significantly reduce the composite risk of death, ICD shocks, and VT-related complications compared to antiarrhythmic drug therapy. While procedural risks exist, the overall benefit profile of ablation supports its use as a first-line therapy for managing VT in high-risk patients. These findings represent a pivotal step in refining VT management strategies, offering clinicians and patients evidence-based guidance for improving outcomes
Limitations
The study did not identify which patient characteristics might influence the choice of treatment, nor can the findings be generalised to individuals with heart muscle scarring from causes other than blocked coronary arteries. Despite the available treatments, the occurrence of VT episodes remained significant, highlighting the need for further research and innovation to improve outcomes for these patients.
Original Research
Sapp, J. L., Tang, A. S. L., Parkash, R., Stevenson, W. G. …, VANISH2 Study Team (2024). Catheter Ablation or Antiarrhythmic Drugs for Ventricular Tachycardia. The New England journal of medicine, 10.1056/NEJMoa2409501. Advanced online publication. https://doi.org/10.1056/NEJMoa2409501
Clinical Trial Registration Information
ClinicalTrials.gov. (n.d.). Antiarrhythmics or ablation for ventricular tachycardia 2 (VANISH2). Retrieved November 25, 2024, from https://clinicaltrials.gov/study/NCT02830360
AHA Scientific Sessions 2024 News Release
16 Nov 2024 | AHA Newsroom | Ablation may be better than medication for those with dangerous heartbeat after heart attackAmerican Heart Association Scientific Sessions 2024, Late-Breaking Science Abstract 4159375
Funding
Included - Canadian Institutes of Health Research Heart and Stroke Foundation of Canada, Abbott Medical Devices, Biosense Webster, Inc. Ottawa Heart Institute Research Corporation, Canadian Institutes of Health Research (CIHR), Cardiac Arrhythmia Network of Canada, Abbott, Nova Scotia Health Authority.
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References
1. Chugh SS, Reinier K, Teodorescu C, Evanado A, Kehr E, Al Samara M, Mariani R, Gunson K, Jui J. Epidemiology of sudden cardiac death: clinical and research implications. Prog Cardiovasc Dis. 2008 Nov-Dec;51(3):213-28. doi: 10.1016/j.pcad.2008.06.003. PMID: 19026856; PMCID: PMC2621010.
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