Catheter Ablation or Antiarrhythmic Drugs for First-line AF Therapy

Quick Takes

  • In this meta-analysis of first-line catheter ablation vs. antiarrhythmic drugs (AADs) in patients with paroxysmal atrial fibrillation (AF), ablation use was associated with a 38% reduction in atrial arrhythmias and a 68% reduction in hospitalizations compared with use of AADs.
  • There was a trend toward a greater number of major adverse events in the ablation group, but it was not statistically significant.
  • Catheter ablation may be considered as a first-line strategy in patients with paroxysmal AF compared with the use of AADs.

Study Questions:

What is the safety and efficacy of atrial fibrillation (AF) ablation as first-line therapy when compared with antiarrhythmic drugs (AADs) in patients with paroxysmal AF?


The authors searched the literature for randomized clinical trials with >12 months of follow-up comparing clinical outcomes of ablation versus AADs as first-line therapy in AF.


Six trials met inclusion criteria, including 1,212 patients: 609 were randomized to AF ablation and 603 to AADs. Compared with AADs, catheter ablation use was associated with reductions in recurrent atrial arrhythmia (32% vs. 53%; risk ratio [RR], 0.62), with a number needed to treat with ablation to prevent one arrhythmia of five. Ablation was also associated with reduced symptomatic atrial arrhythmia (11.8% vs. 26.4%; RR, 0.44) and hospitalization (5.6% vs. 18.7%; RR, 0.32) with no significant difference in serious adverse events between the groups (4.2% vs. 2.8%; RR, 1.52; p = not significant).


This meta-analysis shows that catheter ablation is associated with reductions in recurrence of atrial arrhythmias and hospitalizations, compared with AADs. There were no differences in major adverse events.


Catheter ablation for paroxysmal AF has long been shown to be effective in patients who have failed antiarrhythmic medications. A number of studies, both radiofrequency and cryoablation, examined clinical outcomes among patients who underwent ablation as initial treatment strategy. The current systematic review and meta-analysis shows significant reductions in arrhythmia recurrence and hospitalizations in patients who underwent ablation, compared with membrane-active antiarrhythmic medications. Ablation was associated with a 38% reduction in atrial arrhythmias and a 68% reduction in hospitalizations, compared with the drugs. This does not necessarily mean that all patients with paroxysmal AF should have an ablation. Catheter ablation is an invasive procedure, and the risks are upfront. The findings of this meta-analysis converge with results of the recent multicenter trial (EAST-AFNET 4), which demonstrated early rhythm control with either drugs or ablation to be associated with improved cardiovascular outcomes in patients with recently diagnosed AF. Patients with prevalent cardiovascular conditions may benefit from early treatment of AF, even if they are minimally symptomatic or asymptomatic.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Cryosurgery, Heart Failure, Hospitalization, Pharmaceutical Preparations, Recurrence, Secondary Prevention, Treatment Outcome

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