Ablation vs Medication as Initial Therapy for Paroxysmal Atrial Fibrillation: An Updated Meta-Analysis of Randomized Controlled Trials

Abstract

Background: Recent randomized controlled trials (RCT) suggest that\nablation is superior to antiarrhythmic drugs (AAD) as an initial therapy\nfor paroxysmal atrial fibrillation (pAF) to prevent arrhythmia\nrecurrences. We performed an updated meta-analysis of RCTs, to include\nrecent data from cryoballoon-based ablation, and to compare\narrhythmia-free survival and adverse events between ablation and AAMs.\nMethods: We searched MEDLINE and EMBASE from inception to December 2020.\nWe included RCT comparing patients with pAF undergoing ablation or\nreceiving AADs as an initial therapy. We combined data using the\nrandom-effects model to calculate hazards ratio (HR) for arrhythmia-free\nsurvival and odds ratio (OR) for adverse events. Results: Five studies\nfrom 2005-2020 involving 985 patients were included (495 patients and\n490 patients underwent ablation and medication as initial therapy,\nrespectively). Patients who underwent ablation had higher freedom from\natrial tachyarrhythmias (AT) during the 12-24 months follow-up period\n(pooled HR=0.48, 95% CI:0.40-0.59, p<0.001) (Figure 2). In a\nsubgroup analysis of ablation method used, both cryoablation group\n(pooled HR=0.49, 95% CI:0.38-0.64, p<0.001) (Figure 2A) and\nradiofrequency ablation group (pooled HR=0.47, 95%CI:0.35-0.64,\np<0.001) (Figure 2B) showed reduction in AT recurrence\ncompared to AAD group. There were no differences in adverse events\nincluding cerebrovascular accident, pericardial effusion or tamponade,\npulmonary vein stenosis, acute coronary syndrome, deep vein thrombosis\nand pulmonary embolism, and bradycardia requiring a pacemaker.\nConclusion: Catheter ablation (both cryoablation and radiofrequency\nablation) is superior to AAD as an initial therapy for pAF in efficacy\nfor reducing AT recurrences without a compromise in adverse events.