Clinical and economic impact of first-line or drug-naïve catheter ablation and delayed second-line catheter ablation for atrial fibrillation using a patient-level simulation model

AimsTo determine the clinical and economic implications of first-line or drug-na & iuml;ve catheter ablation compared to antiarrhythmic drugs (AADs), or shorter AADs-to-Ablation time (AAT) in atrial fibrillation (AF) patients in France and Italy, using a patient level-simulation model.Materials and methodsA patient-level simulation model was used to simulate clinical pathways for AF patients using published data and expert opinion. The probabilities of adverse events (AEs) were dependent on treatment and/or disease status. Analysis 1 compared scenarios of treating 0%, 25%, 50%, 75% or 100% of patients with first-line ablation and the remainder with AADs. In Analysis 2, scenarios compared the impact of delaying transition to second-line ablation by 1 or 2 years.ResultsOver 10 years, increasing first-line ablation from 0% to 100% (versus AAD treatment) decreased stroke by 12%, HF hospitalization by 29%, and cardioversions by 45% in both countries. As the rate of first-line ablation increased from 0% to 100%, the overall 10-year per-patient costs increased from 13,034 to 14,450 in Italy and from 11,944 to 16,942 in France. For both countries, the scenario with no delay in second-line ablation had fewer AEs compared to the scenarios where ablation was delayed after AAD failure. Increasing rates of first-line or drug-na & iuml;ve catheter ablation, and shorter AAT, resulted in higher cumulative controlled patient years on rhythm control therapy.LimitationsThe model includes assumptions based on the best available clinical data, which may differ from real-world results, however, sensitivity analyses were included to combat parameter ambiguity. Additionally, the model represents a payer perspective and does not include societal costs, providing a conservative approach.ConclusionIncreased first-line or drug-na & iuml;ve catheter ablation, and shorter AAT, could increase the proportion of patients with controlled AF and reduce AEs, offsetting the small investment required in total AF costs over 10 years in Italy and France.This study created an individual patient level simulation to estimate the clinical and economic implications of catheter ablation, which is a non-pharmacological option to treat patients with atrial fibrillation (AF). This study examines the impact of the updated 2020 ESC guidelines to managing AF in Italian and French patients comparing antiarrhythmic drug treatment to first- and second-line catheter ablation. Differences in AF-related adverse events (AEs) such as stroke, hospitalization, cardioversions, and bleeding events were considered in the model to inform the overall per-patient costs. The model was tested with 50,000 patient simulations to limit random effects. The results of the patient simulation model revealed that as the frequency of utilizing first-line catheter ablation increased from 0% to 100% compared to pharmacological treatment, AEs were reduced in both countries, resulting in a slightly increased 10-year-per-patient cost. Additionally, for patients who fail first-line pharmacological treatment, those who receive second-line catheter ablation in the next year, versus a delay of one or two years, had the highest rate of cumulative controlled patient years on rhythm control therapy and the lowest AE rate by year 10 of the model. Overall, 10-year per-patient costs were similar, regardless of whether second-line ablation was delivered with no delay or a one-or two-year delay. In conclusion, increased use of first-line catheter ablation and earlier second-line catheter ablation can reduce the rates of adverse clinical events and increase the proportion of patients with controlled AF for a similar investment in per-patient costs over 10-years.