Co-Author(s):
Daniel Musikantow, MD
William Whang, MD
Jacob Koruth, MD
Marc Miller, MD
Noelle Langan, MD
Aamir Sofi, MD
Subbarao Choudry, MD
Srinivas Dukkipati, MD
Vivek Reddy, MD
Mount Sinai Hospital
1, Gustav L. Levy Street, New York, NY-10029
Introduction | Objectives: The recently published multicenter EAST-AFNET4 trial showed that as compared with usual care, early rhythm control of atrial fibrillation (AF) with either antiarrhythmic drugs (AADs) or catheter ablation improved cardiovascular outcomes. The optimal therapeutic modality to achieve early rhythm control is unclear. We performed a meta-analysis of all randomized studies (RCTs) comparing the safety and efficacy of AF ablation as first-line therapy when compared with AADs in patients with paroxysmal AF.
Methods: We searched PubMed, Scopus, Google Scholar, and various major scientific conference sessions from January 1, 2000 until to November 23, 2020 for RCTs that had at least 12 months of follow-up and compared clinical outcomes of ablation versus AADs as first-line therapy in adults with paroxysmal AF. Analysis was performed using random-effects model using Mantel‐Haenszel method and results presented as 95% confidence interval.
Results: Six RCTs met inclusion criteria, including 1,212 patients (ablation=609, AADs=603). Age range 50-60 yrs, mean duration of AF 1.3±2.3 yrs and mean LA diameter was 40±6 mm. In RAAFT ,RAAFT-2 and MANTRA-PAF , ablation was performed using radiofrequency energy while cryoballoon was employed in the STOP AF , EARLY AF , and CRYO-FIRST clinical trials. The AADs arm primarily employed class IC drugs in 82% and class III drugs in 14%.  Study follow-up ranged from 12 to 24 months (mean 16±6 months). Compared with AADs, catheter ablation reduced recurrent atrial arrhythmia (32.3% vs 53%; risk ratio [RR] 0.62, 95% CI 0.51-0.74, p< 0.00001) with a number needed to treat of 5. Ablation also reduced symptomatic atrial arrhythmia (11.8% vs 26.4%, RR 0.44, 95% CI, 0.27 to 0.72, p=0.001) and hospitalization (5.6% vs 18.7%, RR 0.32, 95% CI 0.19 to 0.53, p< 0.00001) with no significant difference in serious adverse events between the groups (4.2% vs 2.8%, RR 1.52, 95% CI 0.81 to 2.85, p=0.19). (Figure )
Conclusions: In this meta-analysis of first-line therapy of patients with paroxysmal AF, as compared to antiarrhythmic drugs, catheter ablation as first-line therapy in patients with paroxysmal AF leads to reductions in AF recurrence and hospitalizations, with no difference in major adverse events.
AFS 2021-41