Long-term clinical outcomes of catheter ablation versus pacemaker implantation in patients with atrial fibrillation and sick sinus syndrome: a multicenter real-world cohort study

Background The comparative long-term clinical outcomes of catheter ablation versus pacemaker implantation in patients with atrial fibrillation(AF) and sick sinus syndrome(SSS) remain controversial. Purpose This study aims to evaluate the long-term clinical outcomes between catheter ablation and permanent pacemaker implantation in patients with AF and SSS utilizing real-world evidence. Methods This population-based cohort study included 1,727 patients with AF and SSS who underwent catheter ablation or permanent pacemaker implantation. After 1:2 propensity score matching (PSM), the final matched cohort comprised 910 patients. The primary clinical outcome was major adverse cardiovascular events (MACE), defined as a composite of all-cause mortality, stroke, hospitalization for worsening heart failure, acute myocardial infarction and revascularization. Secondary endpoints comprised all-cause mortality, stroke, and hospitalization for worsening heart failure. Multivariable Cox regression was used to adjust for confounders, combined with Kaplan-Meier survival analysis to systematically evaluate the robustness of treatment effects. Results The final cohort included 350 patients who received catheter ablation and 560 who received permanent pacemaker implantation. During a mean follow-up of 1,852 days,patients in the catheter ablation group were younger, had higher CHA2DS2-VASc scores, and had a higher prevalence of dyslipidemia compared with the permanent pacemaker group. They were also more likely to be prescribed oral anticoagulants, antiplatelet drugs, statins, and anti-arrhythmic drugs. After PSM, the catheter ablation group was associated with a significantly decreased risk of MACE compared with the permanent pacemaker implantation group (hazard ratio [HR] = 0.53; 95% confidence interval [CI], 0.39–0.70; P < 0.001). Catheter ablation also significantly reduced the risks of all-cause stroke (HR = 0.57; 95% CI, 0.37–0.90; P = 0.014) and hospitalization for worsening heart failure (HR = 0.57; 95% CI, 0.37–0.90; P = 0.014). However, there was no significant difference in the risk of all-cause mortality between the two groups (HR = 0.60; 95% CI, 0.27–1.34; P = 0.20). These findings remained consistent after adjustment in multivariable Cox regression models. Conclusion In this real-world cohort, catheter ablation was associated with a lower risk of MACE, stroke, and hospitalization for worsening heart failure, but a similar risk of all-cause mortality compared with permanent pacemaker implantation. Given the observational nature of this study, further prospective research is warranted to validate the efficacy of catheter ablation in patients with AF and SSS.