Catheter Ablation of Paroxysmal Atrial Fibrillation and Disease Progression: Magnitude of the anti-progression effect and role of intervention timing

Background: Recent randomized controlled trials(RCT) have shown that catheter ablation of paroxysmal atrial fibrillation(AF) is associated with a lower incidence of progression to persistent AF compared to the use of antiarrhythmic drug(AAD) therapy.

Objective: This meta-analysis aimed to investigate the magnitude of the anti-progression effect of catheter ablation, as well as the effect of intervention timing.

Methods: MEDLINE/EMBASE databases were searched until April 1^st 2024 for RCTs comparing catheter ablation and AAD therapy for the treatment of paroxysmal AF and reporting the rate of progression to persistent AF at 3 years (PROSPERO CRD42024534288).

Results: A total of 1,287 references were retrieved, of which 5 RCTs met inclusion criteria. The rate of progression to persistent AF was 8.3% (95%CI: 5.4-11.2, I²= 67.2%) at 3 years. The 3-year rate of progression to persistent AF was significantly lower in patients randomized to catheter ablation (1.8%; 95%CI: 0.3-3.3, I²= 0%) when compared to AAD (14.9%; 95%CI: 9.3-20.5, I²= 71.9%); representing a risk ratio of progression to persistent AF at 3 years of 0.15 (95%CI: 0.08-0.28, I²= 0%, p<0.001) for catheter ablation vs. AAD therapy. Catheter ablation appeared similarly efficient in reducing AF progression when used as first-line or non-first line therapy (RR=0.19 95%CI: 0.07-0.48 and RR=0.13, 95%CI: 0.05-0.29, respectively, p_interaction=0.551).

Conclusion: The risk of progression to persistent AF at 3 years appears to be reduced by almost 7-fold in patients with paroxysmal AF treated using catheter ablation compared to patients treated using AAD therapy, regardless of the timing of the intervention.