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May 12, 2010

Antiarrhythmic Drug Therapy vs Catheter Ablation for Paroxysmal Atrial Fibrillation—Reply

JAMA. 2010;303(18):1808-1810. doi:10.1001/jama.2010.540

In Reply: Dr Viganego and Drs Paydak and Mehta raise important concerns regarding the exclusion of amiodarone as an ADT option and the potential underestimation of ADT benefit in the randomized trial. The use of amiodarone was prohibited because the trial design required that drugs used must have been approved by the US Food and Drug Administration for treatment of AF. Amiodarone has been shown to be more effective than other class I and III drugs in populations containing a substantial proportion of patients with paroxysmal AF.1,2 In those studies, patients had minimal prior ADT exposure, and the results cannot be extrapolated to patients who have already failed 1 or more ADT trials. Other randomized comparisons of ADT vs catheter ablation for paroxysmal AF have included amiodarone but demonstrated much lower efficacy for amiodarone when used as a second or subsequent drug option.3,4 The overall success of ADT, approximately 15% to 20% in our trial, is similar to that reported in the earlier studies. In addition, the long-term toxicity of amiodarone has made it less acceptable for patients and physicians in the treatment of paroxysmal AF when other alternatives are available.