Catheter ablation vs antiarrhythmic medication in atrial fibrillation

The CABANA and CAPTAF trials report more data on the effects of catheter ablation vs. antiarrhythmic medication on quality of life for patients with atrial fibrillation than previously available systematic reviews. However, these publications do not report data for all-cause mortality and cardiac hospitalization in a form that can be integrated into recent meta-analyses. Recent meta-analysis estimates for the effect of catheter ablation on all-cause mortality suggest a reduction in patients with comorbid heart failure with reduced ejection fraction (HFrEF) (risk ratio [RR] 0.52, 95% CI 0.33 to 0.81, n=732, 5 trials) and an unclear effect in patients without comorbid HFrEF (RR 0.88, 95% CI 0.29 to 2.61, n=710, 4 trials). CABANA (n = 2,204) reported mortality for all patients combined (hazard ratio 0.86, 95% CI 0.65 to 1.15), and subgroup analyses by presence or absence of HFrEF would be useful to determine consistency with other trials and, if consistent, increase precision of pooled effect estimates. CAPTAF (n = 155) (which included almost exclusively patients without comorbid heart failure) did not report the mortality outcome data. Both trials collected data on cardiac hospitalization. A recent meta-analysis suggests a reduction in cardiac hospitalization in patients with comorbid HFrEF (RR 0.63, 95% CI 0.46 to 0.87, n=632, 3 trials) and in patients without comorbid HFrEF (RR 0.32, 95% CI 0.23 to 0.45, n=629, 4 trials). Again, however, the CABANA and CAPTAF trials did not report these data in a way that would allow them to be integrated into existing meta-analyses or did not report these data at all. Reporting key clinical outcomes from these trials with subgrouping by comorbid HFrEF could provide substantially more data than the prior body of evidence and inform best current estimates for this comparison.