Ablation versus drug therapy in atrial fibrillation patients with or without prior Pharmacological or direct current cardioversion: results from the CABANA trial

BACKGROUND: Catheter ablation is superior to drug therapy in selected atrial fibrillation (AF) patients, yet the impact of prior non-ablation rhythm control remains unclear. METHODS: We analyzed data from Catheter Ablation vs. Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial, which assessed whether catheter ablation was more effective than drugs for improving outcomes in AF patients, including paroxysmal, persistent and long-standing persistent AF. In this study, patients were stratified by whether they had pharmacological or direct current cardioversion (P/DCCV) before randomization. The primary outcome was a composite of all-cause death, disabling stroke, serious bleeding, or cardiac arrest. The secondary outcomes included all-cause death, death or cardiovascular hospitalization, cardiovascular death, AF recurrence and composite of all-cause death, stroke, or cardiovascular hospitalization. RESULTS: In CABANA trial, 1,035 (47.0%) had a history of P/DCCV. The effect of catheter ablation on primary outcome did not differ significantly between patients with prior P/DCCV and those without (HR = 1.00, 95%CI [0.66–1.51] and HR = 0.68, 95%CI [0.45–1.03], respectively). For the secondary outcome of death or cardiovascular hospitalization, catheter ablation reduced risk in both groups, with a greater effect observed in patients with prior P/DCCV (HR = 0.72, 95%CI [0.61–0.85] vs. HR = 0.91, 95%CI [0.78–1.07], respectively; P for interaction = 0.032). Ablation also significantly reduced AF recurrence in both groups and improved AF-related quality of life over 60 months of follow-up. CONCLUSION: In this post-hoc analysis of the CABANA trial, catheter ablation was associated with greater benefit in reducing the composite outcome of death or cardiovascular hospitalization among patients with prior P/DCCV.