Safety outcomes of catheter ablation versus antiarrhythmic drugs in atrial fibrillation: a comprehensive systematic review and meta-analysis

Abstract Background and Aims Catheter ablation (CA) is superior to antiarrhythmic drugs (AADs) for maintaining sinus rhythm in atrial fibrillation (AF). However, most randomised controlled trials (RCTs) lack the power to assess CA safety. Hence, we sought to evaluate complication rates and relative risks of CA compared with AADs for the rhythm management of AF. Methods We searched MEDLINE, Embase, and Cochrane CENTRAL (inception–Oct 24, 2024) for RCTs comparing CA vs. AADs in AF management. The primary endpoint was a composite of serious adverse events (SAE), including death, additional intervention, prolonged or unplanned hospitalisation, or disability. Secondary endpoints included SAE components. A random-effects meta-analysis estimated pooled risk ratios (RR) with 95% confidence intervals (CI). Results 24 randomised trials comprising 6,665 participants (53.2% in the CA group) met the inclusion criteria. On follow-up (ranging from 6 to 60 months), 673 (10.1%) patients in either group developed SAEs. CA was associated with a 20% lower risk of serious adverse events compared with AAD (RR 0.80, 95% CI 0.69-0.93, I2 0%, p0.01) and 47% reduction in risk unplanned hospitalisation (RR 0.53, 95% CI 0.38-0.72, I2 73%, p0.01). Additionally, compared to AAD, CA was associated with a 37% lower risk of adverse cardiovascular events related to therapy (RR 0.63, 95% CI 0.44-0.90, I2 42%, p=0.01). Conclusions Catheter ablation for AF rhythm management reduced serious adverse events, unplanned hospitalisation, and adverse cardiovascular events compared to AADs. Across the spectrum of AF, rhythm control with antiarrhythmic drugs should not be preferred to catheter ablation on the grounds of patient safety.