Catheter ablation improves cardiovascular prognosis in patients with atrial fibrillation compared to drug therapy

1. Compared with drug therapy, catheter ablation improved cardiovascular prognosis in patients with atrial fibrillation (AF) and fewer than 3 nonmodifiable recurrence risk factors (NMRRFs), but not in those with 3 or more.

2. Catheter ablation reduced AF recurrence and improved quality of life, irrespective of NMRRF count.

Evidence Rating Level: 2 (Good)

Catheter ablation reduces symptoms of atrial fibrillation (AF) and AF recurrence. However, research on the effectiveness of catheter ablation in reducing major cardiovascular events among patients with varying nonmodifiable recurrence risk factors (NMRRFs) remains limited. This study thus examined the benefits of catheter ablation vs drug therapy in patients with varying numbers of NMRRFs. This study was a post hoc subanalysis of the multinational, multicenter, open-label Catheter Ablation vs Anti-Arrhythmic Drug Therapy for Atrial Fibrillation (CABANA) randomized clinical trial. The follow-up in the primary study was an average of >48 months. In CABANA trial, individuals with AF and at least 1 stroke risk factor were enrolled between November 2009 and April 2016 and followed for an average of >48 months. Participants were divided into 2 groups based on the number of NMRRFs they had (<3 or >3) and randomly assigned to receive either catheter ablation or drug therapy. The 4 NMRRFs considered were AF duration >1 year, persistent or long-standing persistent AF, age >65 years, and female sex. In the drug therapy group, patients started with rate-control medications and transitioned to rhythm-control drugs if rate-control was unsuccessful. The primary endpoint was death, disabling stroke, serious bleeding, or cardiac arrest. Of the 2185 participants included in the study (median [IQR] age = 67.0 [62.0-72.0] years, 1373 males [62.8%]), 1100 (50.3%) received catheter ablation and 1085 (49.7%) received drug therapy. Most patients (1469 [67.2%]) had <3 NMRRFs, while 716 (32.8%) had >3. Compared with the drug therapy group, the catheter ablation group had a reduced primary end point in patients with <3 NMRRFs (adjusted hazard ratio [AHR], 0.59 [95% CI, 0.41-0.86]), but not in those with >3. An interaction was observed between the primary end point and the NMRRF category (P = .003). Across all NMRRF groups, ablation did not reduce all-cause mortality, but reduced AF recurrence (<3 NMRRFs: AHR, 0.46 [95% CI, 0.40-0.52]; ≥3 NMRRFs: AHR, 0.58 [95% CI, 0.49-0.69]) and improved quality of life throughout follow-up for symptom frequency (<3 NMRRFs: −1.63 [95% CI, −2.18 to −1.07]; ≥3 NMRRFs: −1.15 [95% CI, −1.98 to −0.31]). Overall, this study found that catheter ablation compared with drug therapy improved cardiovascular prognosis in patients with AF and fewer than 3 NMRRFs. These findings support a more individualized approach to AF management by tailoring treatment decisions to patients’ risk profiles. Future studies should validate these results and investigate underlying mechanisms. 

Click to read the study in JAMA Network Open

Image: PD

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