Ablation vs Medication as Initial Therapy for Paroxysmal Atrial
Fibrillation: An Updated Meta-Analysis of Randomized Controlled Trials
Background: Recent randomized controlled trials (RCT) suggest that
ablation is superior to antiarrhythmic drugs (AAD) as an initial therapy
for paroxysmal atrial fibrillation (pAF) to prevent arrhythmia
recurrences. We performed an updated meta-analysis of RCTs, to include
recent data from cryoballoon-based ablation, and to compare
arrhythmia-free survival and adverse events between ablation and AAMs.
Methods: We searched MEDLINE and EMBASE from inception to December 2020.
We included RCT comparing patients with pAF undergoing ablation or
receiving AADs as an initial therapy. We combined data using the
random-effects model to calculate hazards ratio (HR) for arrhythmia-free
survival and odds ratio (OR) for adverse events. Results: Five studies
from 2005-2020 involving 985 patients were included (495 patients and
490 patients underwent ablation and medication as initial therapy,
respectively). Patients who underwent ablation had higher freedom from
atrial tachyarrhythmias (AT) during the 12-24 months follow-up period
(pooled HR=0.48, 95% CI:0.40-0.59, p<0.001) (Figure 2). In a
subgroup analysis of ablation method used, both cryoablation group
(pooled HR=0.49, 95% CI:0.38-0.64, p<0.001) (Figure 2A) and
radiofrequency ablation group (pooled HR=0.47, 95%CI:0.35-0.64,
p<0.001) (Figure 2B) showed reduction in AT recurrence
compared to AAD group. There were no differences in adverse events
including cerebrovascular accident, pericardial effusion or tamponade,
pulmonary vein stenosis, acute coronary syndrome, deep vein thrombosis
and pulmonary embolism, and bradycardia requiring a pacemaker.
Conclusion: Catheter ablation (both cryoablation and radiofrequency
ablation) is superior to AAD as an initial therapy for pAF in efficacy
for reducing AT recurrences without a compromise in adverse events.