Meta-analysis: Rhythm control with catheter ablation ‘preferred treatment’ in AF, HFrEF
In patients with atrial fibrillation and concurrent HF with reduced ejection fraction, catheter ablation significantly reduced all-cause mortality compared with medical therapy, according to a new meta-analysis.
Catheter ablation also improved left ventricular EF and atrial arrhythmia recurrence in that population compared with medical therapy, researchers reported.
“The best strategy to manage AF in patients with comorbid heart failure has always been a heatedly debated topic,” Luigi Di Biase, MD, PhD, FHRS, professor of medicine at the Albert Einstein College of Medicine at Montefiore Hospital and section head of electrophysiology and director of arrhythmia services for the Montefiore Health System, told Healio. “Many randomized clinical trials, including the landmark AFFIRM, AATAC, CABANA, CASTLE-AF and EAST-AFNET 4 trials, or their subgroup analyses to date, have shown rhythm control with catheter ablation improves outcomes in patients with AF and HFrEF. However, subgroup analyses are sometimes underpowered. Our study is a meta-analysis that included patients from eight randomized controlled trials to better elucidate the effect of catheter ablation on outcomes in these patients.”
Di Biase and colleagues analyzed data from eight randomized controlled trials with 2,121 participants evaluating the benefit of catheter ablation for adults with AF and HF (mean age, 65 years; 72% men). Across studies, 1,056 patients underwent catheter ablation and 1,065 patients received medical therapy. Mean follow-up across trials was 32.9 months. The primary endpoint was all-cause mortality; secondary endpoints included atrial arrhythmia recurrence and improvement in LVEF.
The findings were published in the Journal of Cardiovascular Electrophysiology.
Researchers found that all-cause mortality in patients who underwent catheter ablation was lower than in the medical treatment group, with rates of 8.8% and 13.5%, respectively, for an RR reduction of 35% (RR = 0.65; 95% CI, 0.51-0.83; P = .0005).
Rates of atrial arrhythmia recurrence were lower in the catheter ablation vs. medical treatment group (39.9% vs. 69.6%; RR = 0.55; 95% CI, 0.4-0.76; P = .0003). Mean improvement in LVEF was greater among participants who underwent catheter ablation compared with medical treatment (9.4% vs. 3.3%; mean difference, 6.2 percentage points; 95% CI, 3.6-8.8; P < .00001).
Researchers also observed greater improvements in functional capacity for those who underwent catheter ablation vs. medical treatment (P = .005).
“As demonstrated in our meta-analysis of randomized controlled trials, rhythm control with catheter ablation should be considered as the preferred treatment modality in patients with AF and HFrEF,” Di Biase told Healio. “Studies have repeatedly shown that maintaining sinus rhythm in patient with HFrEF and AF is key to prevent morbidity and mortality. With the widespread use of catheter ablations in the past few decades, well-designed randomized controlled trials also proved the superiority of catheter ablation in achieving and maintaining sinus rhythm in AF patients compared with medical therapy.”
Di Biase said the favorable outcomes of catheter ablation “should serve as a confidence booster” for both referring clinicians and electrophysiologists to advocate for catheter ablation in patients with AF and HFrEF during medical decision-making.
“We hope more efforts can be directed to patients with AF and HF with preserved EF,” Di Biase said. “HFpEF has always been difficult to manage. It would be interesting to see if rhythm control through catheter ablation could achieve similar favorable clinical and mortality outcomes in patients with HFpEF and AF compared with those with reduced EF.”
For more information:
Luigi Di Biase, MD, PhD, FHRS, can be reached at dibbia@gmail.com; Twitter: @luigidibiasemd.
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