Safety of Catheter Ablation compared with Antiarrhythmic Drugs for Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomised Trials

Background: 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.Objective: To evaluate complication rates and relative risks of CA compared with AADs for AF rhythm management.Methods: MEDLINE, Embase and Cochrane CENTRAL (inception-Oct 24, 2024) were searched 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: Twenty-four randomised trials comprising 6,665 participants were included in the meta-analysis, with 3,554 patients (53.2%) assigned to the catheter ablation group and 3,111 patients (46.7%) to the antiarrhythmic drug group.During a 12-month median follow-up (6-60 months), CA was associated with a 20% lower risk of SAE compared with AAD (RR 0.80, 95% CI 0.69-0.93,I 2 0%, p < 0.01) and 47% reduction in risk unplanned hospitalisation (RR 0.53, 95% CI 0.38-0.72,I 2 73%, p < 0.01).CA was also associated with a 37% lower risk of adverse cardiovascular events (RR 0.63, 95% CI 0.44-0.90,I2 42%, p = 0.01).Conclusions: CA for AF rhythm management reduced SAEs, unplanned hospitalisation and adverse cardiovascular events compared with AADs.When patient safety is being considered, AAD appears to have a less favourable safety profile than catheter ablation in AF.