Key result
Catheter ablation as first-line therapy significantly reduced the recurrence of any atrial tachyarrhythmia compared to anti-arrhythmic drugs (OR 0.42; 95% CI 0.31 to 0.55; p < 0.00001).
Why the study?
Guidelines recommend antiarrhythmic drugs before ablation, and little is known about catheter ablation as first-line therapy for untreated patients with symptomatic atrial fibrillation.
Does catheter ablation reduce the recurrence of atrial tachyarrhythmias compared to antiarrhythmic drugs as first-line therapy in patients with symptomatic atrial fibrillation?
Meta-Analysis (n=986)
Does catheter ablation reduce the recurrence of atrial tachyarrhythmias compared to antiarrhythmic drugs as first-line therapy in patients with symptomatic atrial fibrillation?
Odds Ratio: 0.42 (95% CI 0.31–0.55)
p-value: p=< 0.00001
Catheter ablation as first-line therapy for symptomatic atrial fibrillation significantly reduces the recurrence of atrial tachyarrhythmias compared to antiarrhythmic drugs without increasing major adverse events.
Supports first-line ablation over AADs in symptomatic AF; challenges guideline-mandated drug trial before ablation.
Funding Acknowledgements Type of funding sources: None. Background The current guidelines recommend a trial of antiarrhythmic drugs (AAD) before ablation is considered. However, the concept "first do no harm" plays an integral role in the management of atrial fibrillation. Little is known about ablation as first line therapy for untreated patients with symptomatic atrial fibrillation. Methods Electronic databases (Medline, Scopus, Embase) were searched until 25th November 2020. Unadjusted odds ratios (OR) were calculated from dichotomous data using Mantel Haenszel (M-H) random-effects with statistical significance to be considered if the confidence interval excludes 1 and p < 0.05. Randomised controlled trials (RCTs) evaluating catheter ablation vs AAD as first line therapy were included. The primary outcome of interest was recurrence of any atrial tachyarrhythmia (symptomatic/asymptomatic, atrial fibrillation, atrial flutter and atrial tachycardia). Secondary outcomes included recurrence of symptomatic atrial tachyarrhythmia, major adverse events and cardiovascular adverse events. Results A total of five studies with 986 (Ablation = 496; AAD = 490) participants were included. Patients receiving ablation were less prone to experience any type of atrial tachyarrhythmia when compared to patients receiving anti-arrhythmic drugs (OR 0.42; 95%CI 0.31 to 0.55; p < 0.00001; I²=0) The incidence of symptomatic atrial tachyarrhythmia was also higher in the AAD arm (OR 0.33; 95%CI 0.18-0.62; p = 0.0006; I²=59%). There were no statistically significant differences for major(OR1.30; 95%CI0.85 to 1.98; p = 0.22; I²=0)and cardiovascular adverse events (OR 1.13; 95%CI 0.69-1.86; p = 0.64 I²=0) respectively. Conclusion Catheter ablation was associated with a significantly lower rate of tachyarrhythmia recurrence than conventional anti-arrhythmic drugs, but may also cause adverse events Abstract Figure.
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Razzack et al. (2021) conducted a meta-analysis in symptomatic atrial fibrillation (n=986). Catheter ablation vs. Anti-arrhythmic drugs (AAD) was evaluated on recurrence of any atrial tachyarrhythmia (symptomatic/asymptomatic, atrial fibrillation, atrial flutter and atrial tachycardia) (OR 0.42, 95% CI 0.31 to 0.55, p=< 0.00001). Catheter ablation as first-line therapy significantly reduced the recurrence of any atrial tachyarrhythmia compared to anti-arrhythmic drugs (OR 0.42; 95% CI 0.31 to 0.55; p < 0.00001).
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