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Authors:
Results of a meta-analysis of six randomized, controlled trials in patients with reduced left ventricular ejection fraction Atrial fibrillation (AF) frequently accompanies heart failure, particularly with reduced ejection fraction (HFrEF). A rhythm control strategy theoretically offers the potential for clinical benefit, but antiarrhythmic agents have not been proven to improve outcomes. Catheter ablation of AF might provide clinical benefit without the toxicities of antiarrhythmic agents but might involve procedural risks. In the randomized, controlled CASTLE-AF study (NEJM JW Cardiol Apr 2018 and N Engl J Med 2018; 378:417), patients receiving ablation had reductions in mortality and admissions for heart failure. The current researchers conducted a meta-analysis of six randomized, controlled trials, including CASTLE-AF, of AF ablation in patients with HFrEF. In the 775 patients, ablation compared with physician-directed medication (including rate-controlling agents or antiarrhythmic agents) was associated with lower rates of all-cause mortality (9.0% vs. 17.6%) and HF hospitalizations (16.4% vs. 27.6%). AF ablation was also beneficial in improving left ventricular ejection fraction, 6-minute walk distances, and quality of life. The two approaches had no significant differences in adverse events. |
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COMMENT
The CASTLE-AF trial, the largest of the six studies in the meta-analysis, has provoked much discussion, and the trial has both supporters and detractors. Still, other trials in the meta-analysis show benefits leaning in the same direction. This meta-analysis is a nice summation of the various trials, and the forest plots of the varied endpoints are informative. I expect that this meta-analysis — while not the last word in addressing AF in HFrEF patients — will move some detractors to support AF ablation.