Catheter Ablation More Effective Than Antiarrhythmic Drugs in Symptomatic Paroxysmal AF

hand of female doctor holding an ablation catheter
hand of female doctor holding an ablation catheter to treat cardiac arrhythmias
Researchers examined the efficacy and safety of catheter ablation compared with antiarrhythmic drugs as a first-line treatment in symptomatic paroxysmal atrial fibrillation.

For patients with symptomatic paroxysmal atrial fibrillation (AF), catheter ablation compared with antiarrhythmic drugs (AADs) was found to be a superior first-line therapy, according to findings from a systematic review and meta-analysis published in Heart.

The study authors searched publication databases through March 2021 for randomized clinical trials of first-line therapy for symptomatic AF. The primary efficacy endpoint was first recurrence of AF after the blanking period; the primary safety endpoint was a composite of all serious adverse events.

A total of 6 prospective, multicenter, randomized trials including 609 patients who received catheter ablation and 603 who received AADs were included in the current analysis.

Patients who received catheter ablation and AAD had a mean age of 56.1 and 56.7 years; 69.7% and 67.2% were men; 37.9% and 40.5% had hypertension; 33.1% and 39.9% had a previous cardioversion; 51.0% and 53.6% received beta-blockers; and 12.5% and 10.2% received calcium-channel blockers, respectively.

The primary endpoint was a 36% relative risk reduction in AF recurrence in patients who received catheter ablation compared with AADs (relative risk [RR], 0.64; 95% CI, 0.51-0.80; P <.01; I2=63%).

Stratified by ablation type, radiofrequency ablation and cryoballoon ablation vs AAD was associated with a reduction (RR, 0.65; 95% CI, 0.42-1.01; P =.05) and more effective reduction (RR, 0.61; 95% CI, 0.51-0.73; P <.01) in recurrence of atrial arrhythmias.

Secondary endpoints showed that catheter ablation was associated with reduced risk for recurrence of atrial arrhythmia (RR, 0.53; 95% CI, 0.35-0.79; P <.01; I2=71%), crossover (RR, 0.21; 95% CI, 0.13-0.32; P <.01; I2=0%), and decreased health care utilization (RR, 0.65; 95% CI, 0.48-0.89; P <.01; I2=57%).

There was no evidence for significant differences in serious adverse events (RR, 0.87; 95% CI, 0.58-1.30; P =.49; I2=58%).

The analysis may have been limited by the differing follow-up durations and monitoring strategies among the various clinical trials. In addition, the study authors reported significant study heterogeneity for many of the comparisons.

“Our meta-analysis demonstrates that first-line treatment with [catheter ablation] is superior to AAD therapy in patients with symptomatic paroxysmal AF, as it significantly reduces the recurrence of any atrial arrhythmias and symptomatic atrial arrhythmias, and healthcare resource [utilization] with comparable safety profile, thus benefiting both patients and healthcare systems,” the study authors noted.

Disclosure: Multiple study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.


Imberti JF, Ding WY, Kotalczyk A, et al. Catheter ablation as first-line treatment for paroxysmal atrial fibrillation: a systematic review and meta-analysis. Heart. 2021;107(20):1630-1636. doi:10.1136/heartjnl-2021-319496