Ablation may reduce stroke risk, death, heart failure hospitalization in patients with atrial fibrillation

1. In this systematic review and meta-analysis, catheter ablation was found to reduce overall risk of ischemic stroke, hospitalization for heart failure, and death compared with medical therapy in patients with atrial fibrillation.

2. While surgical ablation reduced the risk of ischemic stroke compared with cardiac surgery alone, it did not produce any significant difference in mortality or heart failure hospitalizations.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Cardiac ablation technology, particularly involving the use of catheters to deliver energy, has resulted in a dramatic reduction in the recurrence of atrial fibrillation (AF). However, whether ablation for AF influences risk of ischemic stroke, death, and hospitalization for heart failure (HF) remains unclear; while positive results have been reported in some large observational trials, they have not been consistently replicated. This meta-analysis aimed to compare the efficacy of catheter ablation versus medical therapy, and surgical ablation versus cardiac surgery in reducing stroke, death, and hospitalization for HF. Catheter ablation was shown by a meta-analysis of nearly forty trials to reduce risk of ischemic stroke compared with medical therapy, although patients undergoing ablation did have higher rates of ischemic stroke in the month immediately following the procedure. Patients who underwent catheter ablation also had fewer hospitalizations for HF, as well as lower absolute mortality which became more pronounced with longer follow-up. Surgical ablation was shown by a separate analysis of over twenty trials to reduce risk of stroke compared with surgery alone, but there was no significant difference in mortality or HF hospitalization. The generalizability of this study was limited by a lack of access to patient data, participant crossover, and the fact that the specific cardiac surgeries assessed differed between studies. Nevertheless, this study suggested that catheter and surgical ablation were associated with improved clinical outcomes among patients with AF.

Click to read the study in AIM

Relevant Reading: Impact of Catheter Ablation on Long-Term Outcomes in Patients With Atrial Fibrillation: A Meta-Analysis

In-Depth [systematic review and meta-analysis]: This systematic review and meta-analysis aimed to determine the efficacy of cardiac ablation versus medical therapy and of surgical ablation versus cardiac surgery in reducing ischemic stroke risk, death, and hospitalization from HF. Studies were included if they were randomized controlled trials of adults with AF who received catheter or surgical ablation versus no ablation. The control in catheter ablation studies was medical therapy, while the control in surgical ablation studies was cardiac surgery without ablation. The primary outcome was the rate of ischemic stroke over 30 days after treatment began, while secondary outcomes included rate of ischemic stroke within 30 days of treatment, ischemic strokes overall, total strokes, all-cause mortality, and total HF hospitalizations. A total of 63 randomized controlled trials were included, yielding a population of 11,161 participants. Catheter ablation was found to reduce the risk of ischemic stroke after 30 days (risk ratio [RR], 0.63 [95% CI, 0.43 to 0.92]), with an absolute reduction of 0.7% compared with medical therapy. It also reduced total risk for ischemic stroke (RR, 0.77 [95% CI, 0.55 to 1.09]) and strokes of any cause (RR, 0.77 [95% CI, 0.57 to 1.05]). However, rates of ischemic stroke within 30 days of treatment were higher for catheter ablation compared with medical therapy (0.5% vs. 0.1%; RR, 6.81 [95% CI, 1.56 to 29.8]). Catheter ablation also reduced HF hospitalization compared with medical therapy (RR, 0.68 [95% CI, 0.55 to 0.85]). Lastly, catheter ablation reduced total mortality (RR, 0.73 [95% CI, 0.60 to 0.88]) and yielded an absolute reduction of 1.6% compared with medical therapy; it reduced all-cause mortality beyond 30 days (RR, 0.73 [95% CI, 0.60 to 0.88]) but not at or before 30 days (RR, 0.88 [95% CI, 0.06 to 14.0]). Surgical ablation reduced the risk for ischemic stroke after 30 days (RR, 0.63 [95% CI, 0.37 to 1.06]) and yielded an absolute reduction of 1.4% compared with surgery without ablation. Surgical ablation also showed lower rates of ischemic stroke within 30 days of treatment compared with no ablation (0.7% vs. 1.2%, RR, 0.56 [95% CI, 0.21 to 1.46]), and reduced the overall risk of ischemic stroke (RR, 0.54 [95% CI,  0.34 to 0.86]) and of all strokes (RR, 0.54 [95% CI, 0.35 to 0.82]). However, there was no effect on mortality (RR, 0.90 [95% CI, 0.70 to 1.15]) or HF hospitalization (RR, 0.90 [95% CI, 0.60 to 1.35]) compared with cardiac surgery. Overall, this study suggested that, among patients with AF, catheter ablation was generally effective in improving clinical outcomes, while surgical ablation was only effective in reducing risk of strokes.

Image: PD

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