Is catheter ablation of atrial fibrillation as first-line treatment ready for prime time?

Atrial fibrillation (AF) is the most common arrhythmia and is associated with increased risk of thromboembolic events, heart failure and mortality.1 In addition, many patients have symptomatic episodes of AF and quality of life is impaired. In this group of patients, rhythm control management is the preferred therapy of choice. Anti-arrhythmic drugs (AADs) have long been the most often used treatment modality for symptomatic AF. The last decades, catheter ablation (CA) has emerged as an alternative treatment option, especially in patients with failed AAD treatment.2 Studies comparing CA and AADs demonstrated superiority of CA in patients with previous failed AAD treatment.3 Recently, numerous studies comparing CA and AAD as first-line treatment for symptomatic AF have been reported. Imberti et al reported a systematic review and meta-analysis of six randomised clinical trials (RCTs) comparing these two treatment arms in patients with predominantly paroxysmal AF who had no prior treatment with AADs, that is, first-line treatment with CA or AADs.4 Pooled data from six RCTs showed that CA is more effective than AADs in reducing AF recurrences. In addition, side effects were numerically non-significantly different between the two treatment arms. Other factors favouring CA as the preferred treatment were a reduced healthcare utilisation and a lower treatment crossover rate in the CA patients. The strength of the current meta-analysis is that it included medium-to-large-sized RCT using contemporary ablation techniques. The authors should be congratulated for their important contribution in this rapidly evolving field of CA. The main findings further strengthen the arguments of those supporting first-line treatment of AF with CA. However, …