To the Editor: In their randomized controlled trial, Dr Wilber and colleagues1 concluded that catheter ablation was superior to antiarrhythmic drug therapy (ADT) in patients with paroxysmal atrial fibrillation (AF) refractory to at least 1 antiarrhythmic drug. However, because of the study design it is possible that the effect of ADT might have been underestimated.
By not permitting the use of amiodarone in the control group, the trial failed to compare catheter ablation with the best available ADT for maintenance of sinus rhythm. Among patients in the Canadian Trial of Atrial Fibrillation (half of whom had paroxysmal AF), 69% of those treated with amiodarone were free from AF recurrence after 1 year compared with 37% treated with sotalol or propafenone.2 In the SAFE-T trial, amiodarone was 6 times more effective than sotalol by intention-to-treat analysis in maintaining sinus rhythm in patients with persistent AF.3 In the study by Wilber et al, only 6% and 10% of patients in the catheter ablation and the control groups, respectively, had failed treatment with amiodarone prior to study enrollment. Amiodarone may not be an ideal antiarrhythmic drug because of its toxicity profile, but it would still be valuable if the authors indicated why its use was not allowed in this trial.