Catheter Ablation Favored Over Medical Therapy in HF With Atrial Fibrillation

In patients with comorbid atrial fibrillation (AF or AFib) and heart failure (HF), catheter ablation (CA) is associated with better functional capacity and left ventricular ejection fraction (LVEF) improvements compared with medical therapy (defined as rate or rhythm control strategy). These findings were published in the International Journal of Cardiology.

Investigators from the University of Pavia in Italy searched publication databases through June 2022 for studies comparing the outcomes of CA and medical therapy among patients with AF and HF. The final dataset included 9 randomized controlled trials and 3 observational studies.

The study population comprised 41,377 patients, among whom 37,766 received medical therapy and 3611 CA. The patients were evenly split between genders, 84% had hypertension, 34% had diabetes, and 23% had persistent AF. Nearly a third of patients (31%) had ischemic disease etiology.

During a median follow-up of 12.75 months, CA was associated with significant improvements to LVEF (mean difference [MD], 6.17; 95% CI, 2.98-9.37; P =.0002) and the 6-minute walking test (MD, 13.70; 95% CI, 3.95-23.45; P =.0006) compared with medical therapy.

In addition, CA tended to be favored over medical therapy for reducing unexpected HF hospitalizations (risk ratio [RR], 0.72; 95% CI, 0.51-1.00; P =.05), all-cause mortality (RR, 0.77; 95% CI, 0.59-1.01; P =.06), all-cause hospitalizations (RR, 0.84; 95% CI, 0.68-1.03; P =.09), and composite HF hospitalization and mortality events (RR, 0.77; 95% CI, 0.58-1.02; P =.07).

In the subgroup analyses, CA was associated with significant reductions in all-cause mortality in randomized studies (RR, 0.68; 95% CI, 0.54-0.86; P =.001) but not in observational studies (RR, 1.05; 95% CI, 0.88-1.24; P =.61).

Significant moderation effects were observed for the presence of hypertension with regard to HF hospitalizations (b coefficient, 3%; P =.015), for diabetes with regard to all-cause mortality (b coefficient, 5%; P =.048), and for age with regard to the composite outcome of HF hospitalizations and all-cause mortality (b coefficient, 8%; P =.007).

These findings may be biased, as the investigators did not have access to patient-level data.

“…a rhythm control strategy, based on CA, is associated with a greater improvement in LVEF and in functional capacity and might indeed confer a survival benefit in patients with HF and AF,” the researchers wrote. “CA should be considered at an early stage of the disease especially in younger patients with a low risk profile to reduce the risk of HF hospitalization and to improve overall prognosis.”