Progression of persistent atrial fibrillation and impact of ablation: A systematic review and meta-analysis

BACKGROUND Persistent atrial fibrillation (PsAF) is often viewed as an intermediate stage between paroxysmal and permanent atrial fibrillation (AF); however, its progression and management pathways remain poorly characterized. OBJECTIVE The study aimed to quantify progression rates from PsAF to permanent AF, identify predictors, and describe management pathways. METHODS We systematically searched PubMed and Embase to January 2026 for studies reporting progression from PsAF to permanent AF and/or management pathways. 2 reviewers independently extracted data and assessed study quality. Random-effects meta-analysis was used to pool progression rates. RESULTS Of the 21 studies; 17 contributed to the primary meta-analysis. The pooled progression rate from PsAF to permanent AF was 16.42 per 100 person-years (PYs) (95% confidence interval 11.48-23.48). Contemporary studies (≥2015) showed lower rates than earlier cohorts (11.06 vs 21.83 per 100 PY; P = .069). In meta-regression, higher prevalence of prior pulmonary vein isolation was associated with lower progression (rate ratio 0.82 per 10 percentage point increase; 95% confidence interval 0.69-0.97; P = .027). Age, female sex, and heart failure showed no clear study-level associations. Observational data showed relatively low catheter ablation utilization despite increasing availability. CONCLUSION PsAF progression is heterogeneous, with contemporary cohorts suggesting lower rates than historical series. Pulmonary vein isolation exposure is associated with less progression at the population level. These findings may have implications for early rhythm control in PsAF. Standardized end points and contemporary cohorts are needed to refine risk estimates and guide timing and selection for rhythm-control strategies.