Efficacy and Safety of Catheter Ablation vs Antiarrhythmic Drugs as Initial Therapy for Management of Symptomatic Paroxysmal Atrial Fibrillation: A Meta-Analysis

Aminah Abdul Razzack¹, Hassan Mehmood Lak², Suveenkrishna Pothuru³, Sajedur Rahman⁴, Syed Adeel Hassan⁵, Nabeel Hussain⁶, Hala Najeeb⁷, Krishna Theja Reddy⁸, Humera Syeda⁸, Farah Yasmin⁷, Ahmad Mustafa⁹, Sanchit Chawla¹⁰, Muhammad Bilal Munir¹¹, Amr F Barakat¹², Walid Saliba¹³, Oussama Wazni¹³, Ayman A. Hussein^13,*

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¹ Department of Medicine, Dr. N.T.R University of Health Sciences, 520010 Vijayawada, India

² Section of Clinical Cardiology, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA

³ Department of Internal Medicine, Ascension via Christi Hospital, Manhattan, KS 66503, USA

⁴ Jalalabad Ragib-Rabeya Medical College and Hospital, Sylhet 3100, Bangladesh

⁵ Department of Internal Medicine, University of Louisville, Louisville, KY 40203, USA

⁶ Saba University School of Medicine, P.O. Box 1000 The Bottom, Saba, Dutch Caribbean

⁷ Department of Medicine, Dow University of Health Sciences, 74400 Karachi, Pakistan

⁸ UHS Southern California Medical Education Consortium, Temecula, CA 92590, USA

⁹ Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY 10301, USA

¹⁰ Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, USA

¹¹ Section of Electrophysiology, Department of Cardiovascular Medicine, University of California, San Diego, CA 92101, USA

¹² Section of Electrophysiology, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA

¹³ Section of Cardiac Pacing and Electrophysiology, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA

^*Correspondence: husseia@ccf.org (Ayman A. Hussein)
Academic Editors: Yoshiaki Kaneko and Peter A. McCullough

Rev. Cardiovasc. Med. 2022, 23(3), 112; https://doi.org/10.31083/j.rcm2303112

Submitted: 11 November 2021 | Revised: 23 February 2022 | Accepted: 24 February 2022 | Published: 19 March 2022

(This article belongs to the Special Issue Clinical Electrophysiology: Diagnosis and Treatment)

This is an open access article under the CC BY 4.0 license.

Abstract

Background: Catheter ablation is an effective treatment for atrial fibrillation (AF), primarily performed in patients who fail antiarrhythmic drugs. Whether early catheter ablation, as first-line therapy, is associated with improved clinical outcomes remains unclear. Methods: Electronic databases (PubMed, Scopus, Embase) were searched until March 28th, 2021. Randomized controlled trials (RCTs) compared catheter ablation vs antiarrhythmic drug therapy as first-line therapy were included. The primary outcome of interest was the first documented recurrence of any atrial tachyarrhythmia (symptomatic or asymptomatic; AF, atrial flutter, and atrial tachycardia). Secondary outcomes included symptomatic atrial tachyarrhythmia (AF, atrial flutter, and atrial tachycardia) and serious adverse events. Unadjusted risk ratios (RR) were calculated from dichotomous data using Mantel Haenszel (M-H) random-effects with statistical significance considered if the confidence interval (CI) excludes one and p $<$ 0.05. Results: A total of six RCTs with 1212 patients (Ablation n = 609; Antiarrhythmic n = 603) were included. Follow- up period ranged from 1–2 years. Patients who underwent ablation were less likely to experience any recurrent atrial tachyarrhythmia when compared to patients receiving antiarrhythmic drugs (RR 0.63; 95% CI 0.55–0.73; p $<$ 0.00001). Symptomatic atrial tachyarrhythmia was also lower in the ablation arm (RR 0.53; 95% CI 0.32–0.87; p = 0.01). No statistically significant differences were noted for overall any type of adverse events (RR 0.93; 95% CI 0.68–1.27; p = 0.64) and cardiovascular adverse events (RR 0.90; 95% CI 0.56–1.44; p = 0.65) respectively. Conclusions: Catheter ablation, as first-line therapy, was associated with a significantly lower rate of tachyarrhythmia recurrence compared to conventional antiarrhythmic drugs, with a similar adverse effect risk profile. These findings support a catheter ablation strategy as first-line therapy among patients with symptomatic paroxysmal atrial fibrillation.