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Original research
Catheter ablation as first-line treatment for paroxysmal atrial fibrillation: a systematic review and meta-analysis
  1. Jacopo F Imberti1,2,
  2. Wern Yew Ding1,
  3. Agnieszka Kotalczyk1,3,
  4. Juqian Zhang1,
  5. Giuseppe Boriani2,
  6. Gregory Lip1,
  7. Jason Andrade4,
  8. Dhiraj Gupta1
  1. 1 Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
  2. 2 Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, Modena, Italy
  3. 3 Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland
  4. 4 Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Dhiraj Gupta, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, L14 3PE, UK; dhiraj.gupta{at}


Objective To assess the efficacy and safety of catheter ablation (CA) compared with antiarrhythmic drugs (AADs) as first-line treatment for symptomatic paroxysmal atrial fibrillation (AF).

Methods Systematic review and meta-analysis of randomised controlled trials identified using MEDLINE, Cochrane Library and Embase published between 01/01/2000 and 19/03/2021. The primary efficacy endpoint was the first documented recurrence of atrial arrhythmias following the blanking period. The primary safety endpoint was a composite of all serious adverse events (SAEs).

Results From 441 records, 6 studies met the inclusion criteria. 609 patients received CA, while 603 received AAD therapy. 212/609 patients in the CA group had a recurrence of atrial arrhythmias as compared with 318/603 in the AADs group resulting in a 36% relative risk reduction (risk ratio: 0.64, 95% CI 0.51 to 0.80, p<0.01). The risk of all SAEs was not statistically different between CA and AAD (0.87, 0.58 to 1.30, p=0.49); 107/609 SAE in the CA group vs 126/603 in the AAD group. Both recurrence of symptomatic atrial arrhythmias (109/505 vs 186/504) and healthcare utilisation (126/397 vs 185/394) were significantly lower in the CA group (0.53, 0.35 to 0.79 and 0.65, 0.48 to 0.89, respectively). There was a 79% reduction in the crossover rate during follow-up among patients randomised to CA compared with AAD (0.21, 0.13 to 0.32, p<0.01).

Conclusions First-line treatment with CA is superior to AAD therapy in patients with symptomatic paroxysmal AF, as it significantly reduces the recurrence of any atrial arrhythmias and symptomatic atrial arrhythmias, and healthcare resource utilisation with comparable safety profile.

  • atrial fibrillation
  • catheter ablation
  • meta-analysis
  • arrhythmias
  • cardiac
  • systematic reviews as topic

Data availability statement

Data are available on reasonable request.

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  • JFI and WYD are joint first authors.

  • Twitter @drJasonAndrade, @dhirajguptaBHRS

  • Contributors JFI and WYD contributed equally to this work. JFI contributed to the design of the study, interpreted the data and drafted the manuscript. WYD contributed to the design of the study, interpreted the data and revised the manuscript. AK contributed to the design of the study, interpreted the data and drafted the manuscript, JZ analysed and interpreted the data and drafted the manuscript. DG contributed to the conception of the study, interpreted the data and revised the manuscript and he is the guarantor. GB, JA and GL contributed to the interpretation of the data and revised the manuscript critically for important intellectual content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests DG: institutional research grants from Boston Scientific, Medtronic and Biosense Webster and personal advisory fees from Boehringer Ingelheim, Boston Scientific and Abbott. GB: small speaker’s fees from Medtronic, Boston, Biotronik, Boehringer and Bayer, outside of the submitted work. GL: Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim and Daiichi-Sankyo. No fees were received personally. JA: grants and personal fees from Medtronic, grants from Baylis, personal fees from Biosense‐Webster. The other authors declare no conflict of interest.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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