Low-cost effective therapy for atrial fibrillation Joseph Dell%u2019Orfano, MD

Atrial fibrillation has been the subject of numerous clinical trials. Because this arrhythmia has many different presentations and is associated with several different clini-

cal consequences, treatment strate-

gies can vary. The major treatment strategies include prevention of thromboembolism, control of the heart rate, and maintenance of sinus rhythm.

The benefits of anticoagulation have been clearly demonstrated. Several recent clinical trials compared the strategies of heart rate control with rhythm control. These trials showed that there is no survival benefit with either strategy. The choice depends on the clinical situation, and therapy should be tailored to the individual patient.

The Canadian Trial of Atrial Fibrillation (CTAF) provides useful information about patients being initiated on and maintained on antiarrhythmic drug therapy. This trial compared the efficacy of sotalol, amiodarone, and propafenone in the control of atrial fibrillation and found amiodarone to be the most effective.

Atrial fibrillation is also a costly condition. Lumer and Nattel (page 13) examined cost data from patients enrolled in the CTAF trial. Not surprisingly, their analysis showed that amiodarone is also more effective in reducing costs related to atrial fibrillation. Because it is more effective at maintaining sinus rhythm, hospitalizations are reduced and overall costs are reduced.

In a review by Wolf and colleagues, Medicare costs for patients with atrial fibrillation were significantly higher than for age-matched controls without atrial fibrillation.1 This difference was primarily because of the cost of acute hospitalizations, a finding consistent with the results of the study by Lumer and Nattel. Although amiodarone was the most effective method of reducing atrial fibrillation-related costs in this study, we do not know how this compares with patients being treated with heart rate control measures.

If the monthly cost of generic amiodarone is $46.99, and the monthly cost of metoprolol, 100 mg twice daily, is $13.99,2 then heart rate control may reduce costs even further. In fact, atrioventricular junction ablation with pacemaker implantation can significantly reduce hospitalizations and costs. The high up-front cost of this procedure breaks even with the cost of medical therapy after about 2.6 years.3

Conclusion

It is clear that management strategies for atrial fibrillation need to be tailored to the individual patient. Randomized trials show no particular survival advantage for either heart rate control or rhythm control. This study proves that in patients undergoing antiarrhythmic therapy for rhythm control, the most effective therapy, amiodarone, appears to be the most cost effective as well. Other management strategies may reduce costs further.