Comparative Therapeutic Assessment of Atrial Fibrillation in Heart Failure With Reduced Ejection Fraction-A Network Meta-Analysis.

ABSTRACT

BACKGROUND: Catheter ablation (CA) continues to prove to be an intriguing therapeutic option for the management of atrial fibrillation (AF) especially in patients with heart failure with reduced ejection fraction (HFrEF). Recent data have suggested that CA may be a viable first-line strategy for these patients. STUDY QUESTION Is CA more effective in managing patients with AF with HFrEF compared to optimal medical treatment and anti-arrhythmic drugs? DATA SOURCES Randomized controlled trials (RCTs) comparing CA, medical treatment, or antiarrhythmic drugs to each other or a placebo group for the treatment of AF in HFrEF. We performed a comprehensive search in PubMed, Embase, and Cochrane library to identify relevant RCTs. STUDY DESIGN: Our primary outcomes of interest were all-cause mortality, hospitalization for heart failure, and the percentage change in left ventricular ejection fraction. Also, we looked at functional outcomes such as Minnesota Living with Heart Failure Questionnaire and 6-minute walking distance. We used event rates for categorical variables and mean differences between the groups for the continuous variables. We used a frequentist approach employing a graph theory methodology to construct a network meta-analysis model. RESULTS: We ended up with 17 RCTs with 5460 participants and 5 different treatments in our network meta-analysis. Compared to optimal medical therapy, CA was effective in reducing all-cause mortality odds ratio (OR) 0.44 (95% confidence interval, 0.27-0.74; P-value <0.001) and hospitalization for heart failure OR 0.41 (0.28-0.59; P-value <0.001). CA also resulted in improvement in left ventricular ejection fraction OR 9.34 (7.13-11.55; P-value <0.001), Minnesota Living with Heart Failure Questionnaire OR -7.75 (-13.98 to -1.52; P-value <0.01), and 6MWT OR 27.30 (5.27-49.33; P-value <0.02). CONCLUSIONS: CA is the most effective and safe treatment for AF patients with HFrEF. We should consider this as a first-line therapy for the management of these patients.