Perspective:

It has been previously reported that the strategy of catheter ablation versus drug therapy in the CABANA trial did not significantly improve the composite primary clinical outcome (death, disabling stroke, serious bleeding, or cardiac arrest) when analyzed by intention to treat. The study had a significant cross over; ablation to drug, 9%; drug to ablation, 28%. There was a significant reduction in death or cardiovascular hospitalization with ablation, and on as-treated analysis, ablation demonstrated superior efficacy to drug therapy.

The current analysis shows that racial and ethnic minorities treated with ablation had a 68% relative reduction in the primary endpoint and a 72% relative reduction in all-cause mortality (both statistically significant). These benefits, which were not seen in nonminority participants, appear to be due to worse outcomes with drug therapy. The minority population had higher prevalence of EF <40%, symptomatic heart failure, and hypertension. It is not clear why minority populations benefited more from the ablation, but at least in part it may have been related to being sicker. The original CABANA publication did report that among patients with New York Heart Association class II-IV symptoms, there appeared to be a benefit in the primary endpoint and all-cause mortality with ablation. The findings of the current report are very important given that rhythm control strategies, including catheter ablation, are substantially underused in racial/ethnic minorities in North America.