The Cost Utility of Rhythm Control Treatment Sequences in Patients with Atrial Fibrillation: Anti-arrhythmic Drugs Versus Catheter Ablation

Background and Objective: Despite evidence on the cost effectiveness of catheter ablation (CA) as a rhythm control strategy in patients with atrial fibrillation, CAs form a substantial share of medical resource consumption, raising questions about optimal timing and maximum CAs per patient. This study addresses these questions using a newly developed open source model integrating observational and clinical trial data. The objective was to estimate the cost effectiveness of rhythm control strategies including anti-arrhythmic drugs (AADs) and/or CA in different sequences from a societal perspective in the Netherlands. Methods: Time to atrial fibrillation symptom recurrence after a CA was estimated using parametric survival functions estimated on health insurance data (n = 24,286). Relative efficacy of CAs versus AADs was derived from meta-analyses, accounting for previous treatment exposure. Six treatment lines were modeled, incorporating AADs and CAs as rhythm control strategies. Medical and societal costs were included and the model had a lifetime time horizon. Model results were generated in 2024 Euros using Dutch input data with a cost-per-quality-adjusted life-year threshold of €20,000. For the probabilistic sensitivity analyses, we simultaneously varied all parameters across 1000 model runs with 5000 patients each. Results: Treatment sequences including at least one CA were cost effective compared with only AADs. Catheter ablation costs are counterbalanced by reduced medical resource consumption in the years following CA. 51.6% of patients with first-line CA remain symptom free over a lifetime versus 6.9% with AADs. The most cost-effective strategy starts with CA, manages atrial fibrillation recurrences with AADs, and uses a maximum of three repeat ablations. Conclusions: Our model suggests that rhythm control with at least one CA is cost effective compared with only AADs in patients with atrial fibrillation requiring rhythm control. Within shared decision making, first-line CA, followed by AADs to manage atrial fibrillation recurrences, with a maximum of three repeat ablations, represents the most cost-effective strategy for patients with symptomatic atrial fibrillation requiring rhythm control.