Catheter Ablation and Antiarrhythmic Drug Therapy as First- or Second-Line Therapy in the Management of Atrial Fibrillation: Systematic Review and Meta-Analysis

Background—The optimal management of atrial fibrillation remains unclear. We performed a meta-analysis of randomized controlled trials to examine the safety and the efficacy of catheter ablation (CA) when compared with antiarrhythmic drug therapy both as first- and second-line therapy for the maintenance of sinus rhythm in atrial fibrillation. Methods and Results—Several databases were searched from inception to March 2014, which yielded 11 studies with 1481 patients with atrial fibrillation. The outcomes measured were recurrence of atrial tachyarrhythmia and the incidence of adverse events. A subgroup analysis was done to evaluate the efficacy of CA as first- or second-line therapy. There was recurrence of atrial tachyarrhythmia in 222 of 785 (28%) patients who underwent CA and in 451 of 696 (65%) patients who were on antiarrhythmic drug therapy (relative risk, 0.40; 95% confidence interval, 0.31−0.52; P=0.00001). Subgroup analysis revealed a beneficial effect of CA both as a first-line (relative risk, 0.52; 95% confidence interval, 0.30−0.91; P=0.02) and as a second-line (relative risk, 0.37; 95% confidence interval, 0.29−0.48; P<0.00001) therapeutic modality. There was a significantly higher incidence of major adverse events in the CA group when compared with those in the antiarrhythmic drug therapy group (relative risk, 2.04; 95% confidence interval, 1.10–3.77; P=0.02, I2=0%). Conclusions—CA seems to be superior to antiarrhythmic drug therapy in drug naïve, resistant, and intolerant patients with atrial fibrillation. However, it should be performed in carefully selected patients after weighing the risks and benefits of the procedure.