Comparative Effectiveness and Safety of Interventions for Atrial Fibrillation in Heart Failure: A Network Meta‐Analysis of Randomized Trials

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Heart Failure with Atrial Fibrillation (n=5159). Intervention: Atrioventricular node ablation with CRT (AVNA_CRT) or Catheter Ablation (CA) vs. Conventional care (CON). Primary outcome: All-cause mortality (AVNA_CRT vs CON) (OR 0.30, 95% CI 0.12-0.78).

Changjiang Deng; Yixin Xu; Adilai Adilijiang; Zhi‐Long Wang; Ying Pan; Chao Fan; Baichuan Liu; Haoxu Lv; Junrui Hou; Tingting Wu

doi:10.1155/cdr/6035178

January 1, 2026Cardiovascular TherapeuticsOpen Access

Comparative Effectiveness and Safety of Interventions for Atrial Fibrillation in Heart Failure: A Network Meta‐Analysis of Randomized Trials

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Key result

AV node ablation with CRT cuts all-cause mortality ~70% vs conventional care in HF with AF.

OR 0.30
95% CI 0.12-0.78
n=5,159

Why the study?

Patients with HF and AF face high risks of death and HF decompensation, yet the comparative effectiveness of commonly used AF management strategies remains uncertain.

Do different atrial fibrillation management strategies, such as catheter ablation or AV node ablation with pacing, reduce all-cause mortality and heart failure hospitalization in adults with concurrent heart failure and atrial fibrillation?

Study Design

Type

Meta-Analysis (n=5,159)

Blinding

Mixed (single-blind and open-label)

Randomization

Randomized

Multicenter

Yes

Structured PICO

Do different atrial fibrillation management strategies, such as catheter ablation or AV node ablation with pacing, reduce all-cause mortality and heart failure hospitalization in adults with concurrent heart failure and atrial fibrillation?

P

Population

5,159 adults with clinically diagnosed heart failure and documented atrial fibrillation enrolled across 23 randomized trials evaluating various rhythm and rate control strategies.

I

Intervention

Atrial fibrillation management strategies including catheter ablation (CA), atrioventricular node ablation plus cardiac resynchronization therapy (AVNA_CRT), atrioventricular node ablation plus right ventricular pacing (AVNA_RV), medical rate control (MRC), and drug-based rhythm control (RhythmDrug).

C

Comparator

Conventional or usual care AF management (CON), as well as direct and indirect comparisons between the specific interventions.

O

Outcome

All-cause mortality and heart failure hospitalization.hard clinical

Main Result

Odds Ratio: 0.3 (95% CI 0.12–0.78)

In patients with heart failure and atrial fibrillation, AV node ablation with CRT and catheter ablation improve survival compared to conventional care, and AV node ablation should be paired with CRT rather than RV pacing to reduce heart failure events.

Limitations

Substantial clinical and methodological heterogeneity across trials, including variation in HF phenotype, AF type, and background GDMT
Uneven evidence network with limited direct head-to-head comparisons for some nodes, leading to imprecise estimates
CV mortality was infrequent and variably defined across trials, reducing power to detect differences
QoL was assessed using different instruments, necessitating SMDs and limiting direct clinical interpretation
Safety reporting was not standardized and adverse events were inconsistently defined
Small-study effects could not be fully excluded
Sparse network geometry with a limited number of studies within most network contrasts
Deviations from intended interventions and missing outcome data in some included trials
Wide confidence intervals for heart failure hospitalization and some all-cause mortality comparisons
Significant global and local inconsistency in the Quality of Life (QoL) network
Possibility of small-study effects cannot be excluded

Implication

Supports AVNA-CRT or catheter ablation to lower mortality in HF with AF; reinforces network RCT evidence over conventional care.

Abstract

BACKGROUND: Patients with HF and AF face high risks of death and HF decompensation, yet the comparative effectiveness of commonly used AF management strategies remains uncertain. This study is aimed at comparing the efficacy and safety of different interventional and medical approaches using NMA of RCTs. METHODS: PubMed, Embase, CENTRAL, Web of Science, and Google Scholar were searched from inception to November 30, 2025, without language restrictions. Parallel-group RCTs enrolling adults with clinically diagnosed HF and documented AF were eligible if they compared at least two AF management strategies, including CA, AVNA with CRT or RV pacing, MRC, drug-based rhythm control (rhythm drug), or CON. Primary outcomes were all-cause mortality and HF hospitalization; secondary outcomes were worsening HF, CV mortality, QoL, and LVEF. Random-effects NMA was performed in Stata 17.0, reporting ORs and SMDs with 95% CIs; treatments were ranked using SUCRA. RESULTS: Twenty-three RCTs (5159 patients) were included. For all-cause mortality (21 trials; 5095 patients), AVNA_CRT (OR, 0.30; 95% CI, 0.12-0.78) and CA (OR, 0.53; 95% CI, 0.35-0.82) were associated with lower mortality than CON; AVNA_CRT also outperformed MRC (OR, 0.35; 95% CI, 0.15-0.79) and AVNA_RV (OR, 0.49; 95% CI, 0.25-0.96). For HF hospitalization (9 trials; 3491 patients), AVNA_CRT reduced risk compared with AVNA_RV (OR, 0.20; 95% CI, 0.04-0.94). For worsening HF (7 trials; 2542 patients), AVNA_CRT was superior to AVNA_RV (OR, 0.41; 95% CI, 0.20-0.84). CA improved QoL versus AVNA_CRT (SMD, -0.94; 95% CI, -1.83 to -0.05) and MRC (SMD, -0.73; 95% CI, -1.22 to -0.24), and improved LVEF versus MRC (SMD, 1.49; 95% CI, 0.57-2.41). No between-strategy differences were clearly demonstrated for CV mortality. CONCLUSION: In RCT evidence for HF with AF, AVNA_CRT and CA were associated with more favorable prognostic outcomes, and CA provided more consistent improvements in QoL and LVEF. When AVNA is selected, CRT should be preferred over RV pacing. Strategy choice should be individualized to clinical goals, patient phenotype, and procedural feasibility.

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Published by Cardiovascular Therapeutics · CC BY

Cite This Study

Deng et al. (2026) conducted a meta-analysis in Heart Failure with Atrial Fibrillation (n=5,159). Atrioventricular node ablation with CRT (AVNA_CRT) or Catheter Ablation (CA) vs. Conventional care (CON) was evaluated on All-cause mortality (AVNA_CRT vs CON) (OR 0.30, 95% CI 0.12-0.78). AV node ablation with CRT (OR 0.30) and catheter ablation (OR 0.53) significantly reduced all-cause mortality compared to conventional care in patients with heart failure and atrial fibrillation.

synapsesocial.com/papers/6a6f5e8a5d37378ac1dc6ee9 https://doi.org/10.1155/cdr/6035178