Network meta-analysis of catheter ablation, rhythm control, and rate control strategies in atrial fibrillation with heart failure impact on mortality, cardiac function, and quality of life

Objective This network meta-analysis evaluated the comparative efficacy and safety of catheter ablation (CA), rhythm control (RhC), rate control (RC), and combined rhythm and rate control (Rh + RC) in patients with heart failure (HF) and atrial fibrillation (AF), focusing on key outcomes including left ventricular ejection fraction (LVEF), brain natriuretic peptide (BNP), mortality, hospitalization, AF recurrence, quality of life assessed by the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and adverse events. Methods A systematic literature search was conducted across PubMed, EMBASE, and the Cochrane Library databases from January 2005 to March 2025 to identify randomized controlled trials (RCTs) assessing these strategies. This study followed PRISMA-NMA guidelines and was prospectively registered in PROSPERO (CRD420251012504). Bayesian network meta-analysis was performed to synthesize direct and indirect evidence. Binary outcomes were reported as odds ratios (ORs), and continuous outcomes as mean differences (MDs) or standardized mean differences (SMDs), with 95% confidence intervals (CIs). Risk of bias was assessed using the Cochrane ROB 2.0 tool. Visual inspection of comparison-adjusted funnel plots was conducted to evaluate publication bias. The certainty of evidence for each primary outcome was assessed using the GRADE approach, and results were summarized in a Summary of Findings table. Results A total of 16 RCTs involving 5,721 patients with HF and AF were included in the analysis. Catheter ablation was superior to other strategies in improving left ventricular ejection fraction (LVEF) MD = 0.34, 95% CI (0.17–0.50) and reducing brain natriuretic peptide (BNP) levels MD = −0.56, 95% CI (−0.72–−0.39). CA significantly reduced all-cause mortality OR = 0.58, 95% CI (0.42–0.80) and heart failure-related hospitalization rates OR = 0.62, 95% CI (0.40–0.96) compared with combined rhythm and rate control. Rhythm control and rate control demonstrated intermediate efficacy across evaluated outcomes. Rh + RC notably improved MLHFQ score, yet showed relatively limited efficacy regarding primary clinical endpoints. No statistically significant differences were observed among the strategies in the incidence of adverse events; however, surface under the cumulative ranking curve (SUCRA) analyses suggested a marginal tolerability advantage for Rh + RC. GRADE evaluation indicated moderate to high certainty for most key outcomes. Conclusion CA is significantly superior in improving cardiac function, reducing mortality, and lowering hospitalization in HF patients with AF. RhC and RC remain reasonable alternatives for specific outcomes, while Rh + RC may benefit select patient subsets regarding MLHFQ score. Certainty of evidence assessments support prioritizing CA where feasible. Comprehensive clinical decisions should integrate patient comorbidities, procedural risks, and longterm outcomes. Future largescale trials are warranted. Systematic review registration https://www.crd.york.ac.uk/prospero/ , identifier CRD420251012504.