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