THE BOTTOM LINE

For patients with paroxysmal atrial fibrillation (PAF), catheter ablation was a superior therapy compared to antiarrhythmic drugs in reducing both atrial fibrillation and hospitalizations without an increase in adverse events.

Why This Is Important

  • ■ Paroxysmal atrial fibrillation (PAF) is on the rise with 454,000 hospitalizations and 158,000 deaths annually in the USA.1

  • ■ One in seven patients admitted with PAF is readmitted within 30 days due to a recurrence of the arrhythmia.1

  • ■ The goal of PAF treatment is to reestablish a normal heart rhythm. This is called cardioversion. The two main PAF treatments are as follows:

    • Antiarrhythmic drugs which are oral medications that can return the heart to its normal rhythm. Some are toxic and poorly tolerated.2

    • Catheter ablation which is a procedure that can eliminate the abnormal heart rhythm. This involves sending a wire that transmits radiofrequency waves, microwaves, lasers, or low temperatures to the area of the heart causing the arrhythmia.

Setting

Meta-analysis of six randomized controlled clinical trials (RCTs) conducted from January 2000 to November 2020 (Fig. 1).3 The studies were selected for being RCTs with at least 12 months of follow-up, having tested ablation versus antiarrhythmic drug on patients 18 years of age and older with AF, and reporting at least one clinical outcome.

Participants and Interventions

The six studies comprised 1212 participants with no prior treatment receiving first-line treatment for symptomatic PAF, 609 of whom were randomized to catheter ablation and 603 to drug therapy. The mean age of the participants was 56 (SD 11.0) years.

Clinical Outcomes

The primary outcome was freedom from recurrent atrial arrhythmia up to 2 years. The secondary outcomes were the recurrence of symptomatic atrial arrhythmia and the rate of readmission. Adverse events were also measured.

Results

  • ■ Ablation resulted in significantly more patients being free from a recurrent atrial arrhythmia: ablation = 53.0% vs. drugs = 32.3% (p < 0.001).

  • ■ Ablation had a significantly lower rate of recurrence of symptomatic atrial arrhythmia: ablation = 11.8% vs. drugs = 26.4% (p = 0.001).

  • ■ Ablation had a significantly lower rate of all-cause hospitalizations after the treatment for PAF: ablation = 5.6% vs. drugs = 18.7% (p < 0.001).

  • ■ Ablation did not have a significantly greater rate of adverse events: ablation = 4.2% vs. drugs = 2.8% (p = NS).

    Figure 1
    figure 1

    The rate of atrial arrhythmia recurrence, all-cause hospitalization, and adverse events up to 2 years after catheter ablation vs. antiarrhythmic drug therapy.

    Full size image

Tips for Discussion with Patients

Catheter ablation was a superior therapy compared to antiarrhythmic drugs in reducing both atrial fibrillation recurrence and hospitalization.

Study Quality and Application to Patients

As with any meta-analysis, there were methodologic differences between the studies. A majority of enrolled patients had normal ejection fractions without significant cardiac disease and pre-existing comorbidities. This may have affected generalizability. Still, study heterogeneity was moderate and a sensitivity analysis did not detect significant differences between the studies. Similarly, the mean age of enrolled participants was 56 while a higher prevalence of PAF has been seen among people 70 years of age. However, older patients have been shown to benefit from catheter ablation.4 The studies were not blinded and were industry-sponsored which could have affected study results.