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Michael Nabauer, Andrea Gerth, Karl Wegscheider, Anika Buchholz, Karl Georg Haeusler, Ursula Ravens, Claudia Sprenger, Ulrich Tebbe, Paulus Kirchhof, Günter Breithardt, Gerhard Steinbeck, Prognostic markers of all-cause mortality in patients with atrial fibrillation: data from the prospective long-term registry of the German Atrial Fibrillation NETwork (AFNET): Authors' reply, EP Europace, Volume 24, Issue 11, November 2022, Pages 1872–1873, https://doi.org/10.1093/europace/euac084
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We thank Drs. Ahmad and Usmani for their careful analysis1 and comments on our manuscript on predictors of mortality in atrial fibrillation.2 Registry data will not provide the evidence needed to establish that AF ablation reduces mortality. While estimates from multiple Cox regression in our manuscript indicate a reduced mortality in patients with ablation performed before enrolment in the AFNET registry, it should be kept in mind that enrolment of patients took place between 2004 and 2006,2 hence the early years of AF ablation. Accordingly, patients who had received an AF ablation before enrolment were younger than those without previous ablation (mean age 61.7 +/− 10.1 vs. 68.5 +/− 10.9 years), and a higher proportion of patients undergoing ablation had a CHA2DS2-VASc score of two or less (69.7% vs. 40.6% in patients without previous ablation). While we were able to correct for several known confounders, it is impossible to correct for unmeasured confounders in a non-randomized registry. From our point of view, the number of patients with AF ablation before enrolment (n = 328) precludes analyzing further subgroups, as suggested by Drs. Ahmad and Usmani. Similarly, the important question regarding the prognosis of patients with myocardial infarction and pre-existing AF should be addressed in larger databases3,4 and future trials.
The data from our registry and the published literature provide sufficient information to formulate the hypothesis that AF ablation, as an effective rhythm control therapy, can prevent cardiovascular outcomes associated with atrial fibrillation and thereby reduce deaths. We need clinical trials with optimized care for comorbidities to test this hypothesis.
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Author notes
Conflict of interest: A.B. reports grant support paid to the department from Atrial Fibrillation NETwork (AFNET), German Centre for Cardiovascular Research (DZHK), German Research Foundation (DFG), EU Horizon 2020, Innovationsfond Neue Versorgungsformen, Biotronik, Daiichi Sankyo, Preventicus, Corsano/MMT and Getemed, outside the submitted work. K.W. reports personal fees from Biotronik, Boston Scientific and Novartis, and grant support from German Federal Ministry for Education and Research (BMBF), Atrial Fibrillation NETwork (AFNET), German Centre for Cardiovascular Researcher, EU Horizon 2020, Adrenomed AG and Biotronik, outside the submitted work. K.G.H. reports a study grant by Bayer, lecture fees/advisory board fees from Abbott, Alexion, AMARIN, AstraZeneca, Bayer, Biotronik, Boehringer Ingelheim, Bristol-Myers-Squibb, Daiichi Sankyo, Edwards Lifesciences, Medtronic, Pfizer, Premier Research, SUN Pharma and W. L. Gore & Associates. U.R. receives research support for a basic science project from AMGEN (USA). P.K. receives research support for basic, translational, and clinical research projects from European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (UK), and German Centre for Cardiovascular Research, from several drug and device companies active in atrial fibrillation, and has received honoraria from several such companies in the past but not in the last three years. P.K. is listed as inventor on two patents held by University of Birmingham (Atrial Fibrillation Therapy WO 2015140571, Markers for Atrial Fibrillation WO 2016012783). All other authors have nothing to declare.
