There seems to be a growing concensus that catheter ablation (CA) should be used as a "first-line" treatment for AF in preference to antiarrhythmic drugs (AADs). It seems that AADs are not very effective in preventing AF (maintaining sinus rhythm), and their adverse effects are as bad as those of AF (although different).
There are lots of papers and articles on the topic - some are listed below:
The NICE guidance on AF was last updated in 2021 and still recommends first-line use of AADs, and only recommends ablation if "drug treatment is unsuccessful, unsuitable or not tolerated in people with symptomatic paroxysmal or persistent atrial fibrillation". The rationale for this decision doesn't seem to consider first-line use of ablation, probably because most of the papers on first-line ablation were published too late to be included.
The evidence review for ablation only looked at studies published up to 2020. It included some early studies of first-line ablation (latest was 2017), but they seem to have been thrown into the mix ("pooled meta-analysis") with the other studies where the patients had already had AADs and possibly prior ablations. The quality of evidence was low or very low for all but two of the studies considered. There's an interesting quote in section 1.7.1.3 page 82 (my bold):
The committee agreed that medical treatment had the highest rate of recurrence but the lowest rate of stroke, and that the catheter ablation treatments appeared to have similar efficacy and harms to each other. The committee discussed the higher risk of stroke evident from the data for radiofrequency multielectrode (RF ME) treatment, whilst noting that some of the devices responsible for the higher risk had since been discontinued. Based on this pairwise evidence, the committee concluded that the different ablation techniques appeared to have comparable balances of benefits and harms for paroxysmal AF patients. Whilst ablation appeared to be clearly superior to medical care, both for first line patients and those who had failed at least one anti-arrhythmic drug, the committee recognised that comparisons between ablation techniques were made somewhat complex and unclear by the many pairwise comparisons made.
See NHS treatments for atrial fibrillation and NICE prescribing information for atrial fibrillation.
This interacts with fludrocortisone: predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) (Severity: severe).
This interacts with fludrocortisone: predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) (Severity: severe).
Also, since it's a beta-blocker, hypotension and marked bradycardia are both contra-indications.
This interacts with fludrocortisone: predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) (Severity: severe).
Hypotension and marked bradycardia are both contra-indications for all beta-adrenoceptor blockers (systemic). These include all the beta-blockers licensed in the UK for atrial fibrillation: i.e. atenolol, acebutolol, metoprolol, nadolol, oxprenolol and propranolol. It also includes bisoprolol, which is listed on the NHS website.
According to the NHS "The aim is to reduce your heart rate to less than 90 beats per minute when you are resting", so they shouldn't be considered relevant.
This is a calcium-channel blocker. Severe bradycardia is a contra-indication. Both Diltiazem and Alcohol can increase the risk of hypotension.
This is a calcium-channel blocker. Bradycardia and hypotension are both contra-indications. Verapamil slightly increases the exposure to Edoxaban.
This Nice page lists further information about contra-indications for these drugs:
This is a cardiac glycoside. Interaction: Fludrocortisone is predicted to increase the risk of Digoxin toxicity when given with Digoxin (Severity: severe).
Definitions from Collins dictionary.
| Embolism | A serious medical condition that occurs when an artery becomes blocked, usually by a blood clot. |
| Embolus | Material, such as part of a blood clot or an air bubble, that is transported by the bloodstream until it becomes lodged within a small vessel and impedes the circulation. |
| Fibrin | A white insoluble elastic protein formed from fibrinogen when blood clots: forms a network that traps red cells and platelets. |
| Fibrinolysis | The breakdown of fibrin in blood clots, esp by enzymes. |
| Ischaemia | An inadequate supply of blood to an organ or part, as from an obstructed blood flow. |
| Plasmin | A proteolytic enzyme that causes fibrinolysis in blood clots. |
| Platelet | Platelets are a kind of blood cell. If you cut yourself and you are bleeding, platelets help to stop the bleeding. |
| Thrombin | An enzyme that acts on fibrinogen in blood causing it to clot. |
| Thrombosis | The formation of a blood clot in a person's heart or in one of their blood vessels, which can cause death. |
| Thrombus | A clot of coagulated blood that forms within a blood vessel or inside the heart and remains at the site of its formation, often impeding the flow of blood. |