Key result
First-line PVI for AF linked to ~24% fewer major events vs AADs.
Why the study?
Large-scale, long-term, real-world studies comparing pulmonary vein isolation to antiarrhythmic drugs as first-line therapy for atrial fibrillation remain limited.
Does pulmonary vein isolation reduce a composite of all-cause death, all-cause hospitalization, and heart failure exacerbation compared to antiarrhythmic drugs as first-line therapy in adults with atrial fibrillation?
Cohort (n=5,276)
Yes
Does pulmonary vein isolation reduce a composite of all-cause death, all-cause hospitalization, and heart failure exacerbation compared to antiarrhythmic drugs as first-line therapy in adults with atrial fibrillation?
Effect estimate: HR 0.76 (95% CI 0.71-0.83)
Absolute Event Rate: 42% vs 51.1%
p-value: p=<0.01
In a real-world propensity-matched cohort, first-line pulmonary vein isolation for atrial fibrillation was associated with significantly lower 5-year risks of mortality, hospitalization, and heart failure exacerbation compared to antiarrhythmic drugs.
Should not yet change first-line atrial fibrillation therapy; leaves open randomized confirmation of pulmonary vein isolation benefit.
Background Pulmonary vein isolation (PVI) has increasingly demonstrated superiority over antiarrhythmic drugs (AAD) for rhythm control in atrial fibrillation (AF). However, large-scale, long-term, real-world studies comparing these two therapies as first-line AF management remain limited. Methods Using the TriNetX network, we identified patients (≥18 years old) with AF between 2012 and 2019. Patients were categorized into two cohorts: PVI vs. AAD as first-line therapy for AF. Patients were followed for 5 years, with the primary outcome being a composite of all-cause death, all-cause hospitalization, and heart failure exacerbation. Secondary outcomes included ischemic stroke and major bleeding events (intracranial bleeding/ gastrointestinal bleeding). Subanalyses were performed in the paroxysmal and persistent AF cohorts, respectively. Results Among 342,230 eligible patients, 2,638 patients (mean age 64.3 ± 10.6 years) who underwent PVI and 2,638 patients (mean age 64.2 ± 13.1 years) who had AAD as first-line therapy for AF had similar propensity scores and were included in the analysis. At 5-year follow-up, the PVI group had a lower risk of the primary composite outcome compared to the AAD group (42.0% vs. 51.1%; HR 0.76; 95% CI, 0.71–0.83; P < 0.01). They also had lower risk of all-cause mortality (4.1% vs. 7.7%; HR 0.53; 95% CI, 0.42–0.67; P < 0.01), all-cause hospitalization (35.1% vs. 42.2%; HR 0.77; 95% CI, 0.71–0.84; P < 0.01), and heart failure exacerbation (21.0% vs. 24.3%; HR 0.85; 95% CI, 0.76–0.95; P < 0.01. Ischemic stroke (6.1% vs. 6.7%; HR 0.90; 95% CI, 0.73–1.12; P = 0.34), and major bleeding event (4.3% vs. 5.3%; HR 0.80; 95% CI, 0.62–1.02; P = 0.08) were similar between groups. Similar outcomes were seen in both the paroxysmal and persistent AF cohorts. Conclusion After a 5-year follow-up period, PVI was associated with better clinical outcomes than AAD as first-line therapy for AF.
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Yeo et al. (2025) conducted a cohort in Atrial Fibrillation (n=5,276). Pulmonary vein isolation vs. Antiarrhythmic drugs was evaluated on Composite of all-cause death, all-cause hospitalization, and heart failure exacerbation (HR 0.76, 95% CI 0.71-0.83, p=<0.01). Pulmonary vein isolation reduced the composite of death, hospitalization, and heart failure by 24% (HR 0.76) compared to antiarrhythmic drugs as first-line therapy for atrial fibrillation.
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