Antiarrhythmic and Other Pharmacological Therapy Postablation
AF recurrences during the first 3 months after ablation are rather common. It is generally believed that the mechanisms of AF in this setting are different from that of the patient’s clinical arrhythmia. Acute inflammatory changes owing to energy delivery1009; modification of the ANS with consecutive changes in the atrial substrate257; or delayed effect of radiofrequency ablation due to lesion consolidation have been considered.258 It is also suggested that AF might resolve completely upon resolution of the transient factors promoting early AF recurrences. Accordingly, suppressive antiarrhythmic agents are frequently prescribed for patients with AF recurrences during the first 1–3 months following ablation.253,436,988,1010,1011 Because ATs can also occur shortly after ablation, negative dromotropic agents (beta or calcium channel blockers) are commonly continued for at least the first month after ablation. The impact of empirical AAD therapy for 6 weeks after AF ablation on the occurrence of AF was investigated in several randomized studies.934,979, 980 The drugs employed for this purpose vary, but most commonly are those that have been used unsuccessfully prior to ablation; they include flecainide, propafenone, sotalol, dofetilide, dronedarone, and amiodarone. The short-term use of AADs after AF ablation decreased early recurrences of atrial arrhythmias and need for hospitalization or cardioversion, but had no effect on the prediction or prevention of arrhythmia recurrence at 6 and 12 months.934,979,980 As noted earlier in this document, the writing group recognizes that the usefulness of initiation or discontinuation of AAD therapy during the postablation healing phase in an effort to improve long-term outcomes is unclear (Class IIb, LOE C-LD, Table 3).
Because an inflammatory process after AF ablation can be one specific cause leading to early recurrences, the efficacy of corticosteroids for preventing early postablation atrial arrhythmias was investigated in several studies.981,982 The prevalence of immediate AF recurrences (≤3 days after PVI) was significantly lower in the corticosteroid group compared with the placebo group (7% vs 31%). However, few investigators routinely administer steroids during or following AF ablation. The use of PPIs or H2 blockers for 1–4 weeks following ablation has been suggested to avoid esophageal ulcerations observed on endoscopy following AF ablation.896,897 However, there are no randomized data available to demonstrate that this approach reduces the incidence of esophageal symptoms or the development of an AEF. Early diagnosis of AEF, with early employment of operative intervention, is the best treatment option for AEF (please refer to Section 10 for more information). Attention to the control of hypertension and addressing other AF risk factors such as sleep apnea and obesity remain an integral part of AF management after the ablation procedure.929 The impact of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the long-term outcome of AF ablation was investigated in a prospective registry of consecutive patients undergoing catheter ablation of paroxysmal or persistent AF.334 In that study, however, modulation of the renin-angiotensin aldosterone system did not appear to affect maintenance of sinus rhythm after catheter ablation of AF. Thus, the hypothesis that so-called medical upstream therapy can positively influence the reverse atrial remodeling after catheter ablation of AF remains unproven.