Dementia Risk of Antiarrhythmic Medication Therapy Vs. Catheter Ablation in Afib Patients

Atrial fibrillation, also known as Afib, is one of the most prevalent conditions in the United States, and yet many patients know very little about it. For many, this is because Afib begins, generally, as mild and paroxysmal or occasional, and as such, once the palpitations or strange feelings have gone away, patients don’t think twice about them. Further, there is a phenomenon known as silent Afib, where the heart beats irregularly without noticeable symptoms. Once again, many patients do not report these, so our prevalence numbers today may be underestimated through simple non-reporting. With that said, however, controlling atrial fibrillation is very important. A fast and irregular heartbeat can cause fatigue and, in the longer term, may increase the risk of heart failure. Immediately, it could also cause pooling of the blood in an outpouching of the heart known as the left atrial appendage, which in turn increases the risk of stroke by five times.

Medical Versus Procedural Treatment Options

When patients first discuss the symptoms of atrial fibrillation with their primary care physician or cardiologist, they may be started on antiarrhythmic medication. These medications help control atrial fibrillation by returning the heart to sinus rhythm. About 50% of patients respond well to these medications, while the other 50% tend to have unacceptable side effects or do not receive the benefits they expect.

While medications are very easy to administer and take, the definitive treatment for atrial fibrillation is known as an ablation. Currently, depending on the area from which the improper electrical signals emanate, there is the option for a cardiac catheter ablation that uses heat to destroy problematic heart tissue. Recently, pulsed field ablation has also been approved, which uses a short burst of electrical current to destroy problematic heart tissue, reducing the risk of collateral tissue damage. Indeed, many patients opt for the procedural route early on as a one-and-done solution.

Dementia Risk Concerns

Interestingly, a relatively recent study compared the risk of dementia between Afib patients taking medications and those opting for procedural options and found that ablation technology may reduce the overall risk of dementia by upwards of 41%. While the overall risk is still relatively low, this difference in dementia risk is not insubstantial.

While overall mortality was not the primary area of study, the study also concluded that overall mortality was reduced by 49% in the ablation cohort versus the medication group.

Our Take on the Results

This is an exciting and significant outcome, not only because the risks are so much lower with ablation (be mindful that since this study was released, we have further refined ablations with pulse field ablation or PFA) but also because ablations are more likely to be a curative option.

A few possibilities emerge in understanding why these results may have been found. First, an ablation is a one-and-done and ultimately localized treatment modality. In other words, the area that is causing the problem is the only area that’s treated. Further, for most patients, one ablation can handle the concern. On the other hand, medication creates systemic effects – effects around the entire body rather than just the treatment area. While these medications can be effective in some patients to minimize or eliminate the arrhythmia, they also have effects elsewhere in the body.

Secondly, it’s essential to discuss delays in treatment when patients are on antiarrhythmics, but they are not fully effective. It’s conceivable that patients would wait for further treatment, even after knowing that their antiarrhythmics aren’t working, which delays care and conceivably makes the arrhythmia worse. This care delay is less of a concern when a catheter ablation is performed. Delayed care also increases the risk of stroke, which, of course, may account for part of the higher all-cause mortality in medication patients versus catheter ablation.

The Bottom Line

When deciding between medication and a procedure, many patients are concerned about going in for a significant but minimally invasive procedure. As such, they often turn to medication as their first option, thinking that it will suffice in controlling their arrhythmia. This is not always the case, however, and the higher risk of dementia, and ultimately, all-cause mortality in atrial fibrillation patients that take medication, is significant enough that patients should have an honest discussion about risk factors with their electrophysiologist.

Fortunately, today’s catheter ablations are safer than ever, and this effective technique has been further improved with the advent of pulsed field ablation. Remember that early treatment often leads to the best outcomes. Speak to your primary care physician about a referral to an electrophysiologist for an appropriate diagnosis and treatment plan.

Sources

Zeitler EP, Bunch TJ, Khanna R, Fan X, Iglesias M, Russo AM. Comparative risk of dementia among patients with atrial fibrillation treated with catheter ablation versus anti-arrhythmic drugs. Am Heart J. 2022 Dec;254:194-202. doi: 10.1016/j.ahj.2022.09.007. Epub 2022 Sep 20. PMID: 36245141.