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.

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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