"Depending on one's current practice, this may be practice-changing, or perhaps practice-reinforcing," Dr. Vivek Reddy of Mount Sinai Hospital in New York City told Reuters Health by email. "The concept of first-line catheter ablation for paroxysmal AF has been out there for a while, even incorporated into the recent European Society of Cardiology guidelines as a potential alternative to drugs."
"Our meta-analysis shows that looking at a number of different first-line therapy trials ranging in time from over a decade ago to the most recent ones published late last year, the data are all quite concordant: ablation is more effective than drugs in maintaining sinus rhythm," he said.
As reported in JAMA Cardiology, Dr. Reddy and colleagues searched the literature from 2000 through 2020 for randomized controlled trials with at least 12 months follow-up comparing first-line ablation versus antiarrhythmic drugs for paroxysmal AF. The main outcomes were safety and efficacy.
Six trials including 1,212 patients (mean age, 56) met the inclusion criteria, with 609 randomized to ablation and 603 to drug therapy. All trials were open-label, used intention-to-treat analysis, and allowed crossover from ablation to drug therapy or vice versa in patients who failed initial therapy.
Compared with drugs, catheter ablation was associated with reductions in recurrent atrial arrhythmia (32.3% vs. 53%; risk ratio, 0.62), with five needed to treat with ablation to prevent arrhythmia in one patient.
Ablation also was associated with less symptomatic atrial arrhythmia (11.8% vs. 26.4%; RR, 0.44) and hospitalization (5.6% vs. 18.7%; RR, 0.32).
There were no significant between-group differences in serious adverse events (4.2% vs. 2.8%; RR, 1.52).
Dr. Reddy noted, "It would be incorrect to conclude from this meta-analysis that everyone who presents with paroxysmal AF must undergo immediate catheter ablation. However, if a patient would prefer ablation over antiarrhythmic drugs, there is no reason to withhold ablation therapy - that is, force patients to try a drug first.
Dr. Deepak Bhatt, Executive Director of Interventional Cardiovascular Programs, Brigham and Women's Hospital Heart and Vascular Center agrees with the findings and told Reuters Health the study was "well done."
That said, he noted, "The average age of the patients in this study was 56 years. Therefore, the results do not apply to older, frail patients in whom invasive therapies may carry greater risks and provide less symptomatic benefit. Also, these results pertain specifically to paroxysmal AF, and not to patients who have been in AF persistently for a long period of time."
"Especially in younger, otherwise healthy patients, catheter ablation can be considered as a first-line therapy (as opposed to antiarrhythmic drugs), especially in patients who are highly symptomatic," he said. "This approach will lead to fewer AF-related hospitalizations."
"Referring physicians should become more aware of this option and refer appropriate patients to cardiac electrophysiologists, who can then discuss the risks and benefits with the individual patient who can the decide on what they want," he added. "Many will pick catheter ablation."
SOURCE: https://bit.ly/3xMi6La JAMA Cardiology, online April 28, 2021.
By Marilynn Larkin
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