Antiarrhythmic drugs versus catheter ablation as rhythm control for atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials

Abstract Anti-arrhythmic drugs (AAD) and catheter ablation are common treatments for rhythm control in patients with atrial fibrillation (AF), but a comprehensive comparison of their benefits and harms is lacking. A systematic review performed by NICE (2021) was updated using a database search in MEDLINE, Embase and Cochrane CENTRAL in October 2024. Selection was conducted independently by two reviewers. Study characteristics and results were extracted by one reviewer and verified by a second. Study quality was assessed using the Cochrane Risk of Bias 2 tool and the certainty of evidence was determined using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Twenty-two studies (31 references) were included in the review. Evidence showed that there may be more recurrence of AF in patients with treatment-naïve paroxysmal AF (relative risk RR 1.76; 95% CI 1.34-2.32) and AAD-exposed persistent AF (RR 1.62; 95% CI 1.40-1.87), and probably more recurrence in patients with paroxysmal AF previously exposed to catheter ablation (RR 2.12; 95% CI 1.61-2.80) when treated with AAD compared to catheter ablation. In both paroxysmal- and persistent AF patients, there may also be more all-cause mortality when treated with AAD versus catheter ablation (RR 1.79; 95% CI 0.80-4.02 and RR 1.45; 95% CI 0.56-3.75, respectively). Incidence of medication side-effects, including gastrointestinal symptoms and syncope, ranged between 0.8 and 3%. Incidence of catheter ablation complications, such as pericardial tamponade and phrenic nerve paralysis, between 0.3 and 2.5%. This review found that, in some subgroups of patients, catheter ablation was better than AAD treatment when considering AF recurrence and mortality. However, catheter ablation has rare but serious complications that should be considered when making informed treatment decisions.