Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial

Inclusion Criteria:

   - Over the preceding 6 months have:

      1. ≥2 paroxysmal (electrocardiographic documentation of at least 1) atrial
      fibrillation (AF) episodes lasting ≥1 hour in duration: (that terminate
      spontaneously within 7 days or cardioversion is performed within 48h of AF
      onset): or

      2. electrocardiographic documentation of 1 persistent AF episode: (sustained for ≥7
      days or cardioversion is performed more than 48h after AF onset): or

      3. electrocardiographic documentation of 1 longstanding persistent AF episode:
      (continuous AF of duration >1 year).

   - Warrant active therapy (within the past 3 months) beyond simple ongoing observation

   - Be eligible for catheter ablation and ≥2 sequential rhythm control and/or ≥2 rate
   control drugs.

   - Be ≥65 yrs of age, or <65 yrs with one or more of the following risk factors for
   stroke: Hypertension (treated and/or defined as a blood pressure >140/90 mmHg) [90],
   Diabetes (treated and/or defined as a fasting glucose ≥126 mg/dl) [91], Congestive
   heart failure (including systolic or diastolic heart failure), Prior stroke, transient
   ischemic attack or systemic emboli, Atherosclerotic vascular disease (previous
   myocardial infarction (MI), peripheral arterial disease or aortic plaque), left atrial
   (LA) size >5.0 cm (or volume index ≥40 cc/m2), or ejection fraction (EF) ≤35.

   - Have the capacity to understand and sign an informed consent form.

   - Be ≥18 years of age.

      - NOTE- Subjects <65 yrs of age whose only risk factor is hypertension must have a
      second risk factor or left ventricular (LV) hypertrophy to qualify.Patients
      receiving new drug therapy initiated within the previous 3 months may continue
      that therapy if randomized to the drug therapy arm. Patients may have documented
      atrial flutter in addition to atrial fibrillation and remain eligible for
      enrollment.

Exclusion Criteria:

   - Lone AF in the absence of risk factors for stroke in patients <65 years of age

   - Patients who in the opinion of the managing clinician should not yet receive any
   therapy for AF

   - Patients who have failed >2 membrane active anti-arrhythmic drugs at a therapeutic
   dose due to inefficacy or side effects (Table 5.2.2)

   - An efficacy failure of full dose amiodarone treatment >8 weeks duration at any time

   - Reversible causes of AF including thyroid disorders, acute alcohol intoxication,
   recent major surgical procedures, or trauma

   - Recent cardiac events including MI, percutaneous intervention (PCI), or valve or
   bypass surgery in the preceding 3 months

   - Hypertrophic obstructive cardiomyopathy (outflow track)

   - Class IV angina or Class IV congestive heart failure (CHF) (including past or planned
   heart transplantation)

   - Other arrhythmias mandating anti-arrhythmic drug therapy (i.e. ventricular tachycardia
   (VT), ventricular fibrillation (VF))

   - Heritable arrhythmias or increased risk for torsade de pointes with class I or III
   drugs

   - Prior LA catheter ablation with the intention of treating AF

   - Prior surgical interventions for AF such as the MAZE procedure

   - Prior AV nodal ablation

   - Patients with other arrhythmias requiring ablative therapy

   - Contraindication to appropriate anti-coagulation therapy

   - Renal failure requiring dialysis

   - Medical conditions limiting expected survival to <1 year

   - Women of childbearing potential (unless post-menopausal or surgically sterile)

   - Participation in any other clinical mortality trial (Participation in other
   non-mortality trials should be reviewed with the clinical trial management center)

   - Unable to give informed consent

      - NOTE- Prior ablation of the cavo-tricuspid isthmus alone is not an exclusion if
      the patient develops subsequent recurrent AF. Planned atrial flutter ablation in
      combination with the left atrial ablation is not an exclusion.