A comprehensive meta-analysis comparing radiofrequency ablation versus pharmacological therapy for the treatment of atrial fibrillation in patients with heart failure

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Highlights

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    In patients with HF and AF, CA showed a positive trend toward a reduction in unexpected HF hospitalization and all cause death, compared with MT

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    Patients treated with CA experienced a better improvement in LVEF and 6-min walking test.

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    Significant benefit of CA in reducing all-cause death was observed in randomized studies but not in observational studies.

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    A positive trend toward a beneficial effect of CA was observed irrespective of the type of HF (HFpEF vs. HFrEF)

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    Younger patients with a low risk profile are those more likely to derive a significant benefit from CA in reducing major clinical endpoints.

Abstract

Background

Atrial fibrillation (AF) and heart failure (HF) are both associated with worse prognosis and often coexist in the same patients. Whether catheter ablation (CA) is superior to pharmacological therapy in reducing major clinical endpoints in patients with AF and HF is still unsettled.

Objective

To conduct a comprehensive meta-analysis comparing CA with medical therapy (MT) in this population.

Methods

We systematically searched for randomized and observational studies comparing clinical outcomes between patients with AF and HF treated with CA or MT. The studied outcomes were mortality, hospitalization, left ventricle ejection fraction (LVEF) and 6-min walking test (6MWT) improvement.

Results

A total of 12 studies counting 41,377 patients (3611 treated with CA and 37,766 with MT) were included in the analysis. The random-effect model revealed a clear trend in favor of CA in reducing unexpected HF hospitalization (RR 0.72; 95%CI 0.51–1.00; P = 0.05), all-cause death (RR 0.77; 95%CI 0.59–1.01; P = 0.06), all-cause hospitalization (RR 0.84; 95%CI 0.68–1.03; P = 0.09), and the composite of HF hospitalization and death (RR 0.77; 95%CI 0.58–1.02; P = 0.07), compared with MT. Patients treated with CA experienced a better improvement in LVEF (mean difference 6.17; 95%CI 2.98–9.37; P = 0.0002) and 6MWT (mean difference 13.70; 95%CI 3.95–23.45; P = 0.006).

When the analysis was limited to randomized controlled trial, CA was found to significantly reduce all-cause death (RR 0.68; 95%CI 0.54–0.86; P = 0.001).

Conclusion

As compared to MT, CA is associated with a better improvement in functional capacity and LVEF, and with a reduction in major clinical endpoints in patients with HF and AF.

Introduction

Atrial fibrillation (AF) and heart failure (HR) are two frequent cardiovascular diseases and often coexist in the same patients [1,2]. These conditions share common risk factors, and their pathophysiological interrelationship is complex and incompletely understood [3]. The development of AF in patients with chronic HF has negative prognostic implications and makes the treatment of both AF and HF more challenging [4]. While guideline-adherent treatment for HF decreases the risk of developing AF [5], the presence of AF may hamper the prognostic benefit of some HF treatments such as beta-blockers or prevent the proper functioning of cardiac resynchronization therapy (CRT) [6]. The optimal AF treatment strategy in patients with HF is still unknown. Despite no clear evidence supports a strategy of rhythm control with antiarrhythmic drugs over a rate control strategy [7], some trials have shown a consistent improvement in symptoms comparing CA with medical therapy (i.e. rate or rhythm control strategy). Nonetheless, the evidence on the impact of CA in reducing mortality and HF hospitalization in this cohort of patient derived from studies with a relatively small number of events, and is not robust enough to draw definitive conclusions, especially outside the highly selected population included in randomized clinical trials (RCTs) [8,9]. The aim of this systematic review and meta-analysis was to summarize the evidence available on this field comparing clinical outcomes in patients with non-permanent AF and concomitant HF treated with CA or medical therapy.

Section snippets

Methods

This study was conducted according to the principles of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) [10].

Included studies

Overall, 1618 titles and abstracts were identified through database searching and 17 full text articles were selected and screened for potential eligibility. Twelve studies (9 RCT [8,9,[12], [13], [14], [15], [16], [17], [18]], 2 observational studies with propensity-matched comparison [19,20] and 1 observational study with unmatched comparison [21] - Fig. S1 – Supplementary material) were included in the final analysis for a total of 41,377 patients (3611 in the ablation group and 37,766

Discussion

CA is nowadays a well-established therapy, and its use is progressively increasing as a consequence of the clear evidence of a net superiority over medical treatment in pursuing the maintenance of sinus rhythm in symptomatic patients with AF. Nevertheless, whether rhythm control is more beneficial than rate control in the prevention of major clinical endpoints is still under debate. This issue is even more relevant in the subset of patients with HF, which are at higher risk of hospitalization

Conclusions

Our metanalysis, the largest so far and the first including both randomized clinical trials and observational controlled studies, clearly suggest that a rhythm control strategy, based on CA, is associated with a greater improvement in LVEF and in functional capacity and might indeed confer a survival benefit in patients with HF and AF. CA should be considered at an early stage of the disease especially in younger patients with a low risk profile to reduce the risk of HF hospitalization and to

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors have no conflicts to disclose.

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    1

    This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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