Ablation vs. drug use for atrial fibrillation

The relative merits of rate and rhythm control in the treatment of patients with atrial fibrillation (AF) have been compared in several major clinical trials, none of which demonstrated a significant difference in all-cause mortality. Yet, there is clear evidence that restoration and maintenance of sinus rhythm is associated with beneficial reverse atrial and ventricular remodelling. In addition, patients may feel better if AF is resolved, and data from some post hoc analyses suggest a possible mortality benefit. These apparently contradictory findings may reflect the high risk of serious adverse events associated with currently available antiarrhythmic drugs (AAD), counterbalancing their beneficial effect in restoring sinus rhythm. Catheter ablation offers an alternative means of restoring sinus rhythm in patients with AF and several clinical trials have indicated superior outcomes in certain subgroups after ablation with or without AAD vs. antiarrhythmic therapy alone. This study reviews the relative advantages and actual use of catheter ablation and other therapeutic options in the treatment of AF, with or without concomitant heart failure or structural heart disease. Catheter ablation is recognized in the latest ACC/AHA/ESC guidelines as a valid second-line option in patients who have failed or were intolerant of first-line antiarrhythmic therapy. In the absence of new antiarrhythmics with an improved benefit/risk profile, it could become a first-line strategy for certain patient populations. The ongoing CABANA trial should confirm its impact on overall survival relative to that of pharmacological rate or rhythm control.