Catheter Ablation vs Antiarrhythmic Agents in Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis

Background Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with increased morbidity and mortality. While catheter ablation and antiarrhythmic drug (AAD) therapy are both established treatment options, their comparative efficacy and safety remain debated. Objective This systematic review and meta-analysis evaluated the effectiveness and safety of catheter ablation versus AAD therapy in adults with AF. Methods A comprehensive search of PubMed, Scopus, Embase, and Web of Science was conducted for randomized controlled trials (RCTs) comparing catheter ablation (radiofrequency or cryoballoon) with AAD therapy. Primary outcomes included atrial arrhythmia recurrence and progression to persistent AF. Secondary outcomes encompass serious adverse events, reintervention rates, and procedure-related complications. Risk of bias was assessed using the RoB 2.0 tool, and certainty of evidence was evaluated using the GRADE framework. Results A total of 24 RCTs involving 9,507 patients were included. Catheter ablation significantly reduced atrial arrhythmia recurrence (RR: 0.57; 95% CI: 0.44–0.73) and progression to persistent AF (RR: 0.12; 95% CI: 0.06–0.24). No difference in serious adverse events was observed between groups (RR: 1.00; 95% CI: 0.84–1.19). However, catheter ablation was associated with a higher risk of reintervention (RR: 36.04; 95% CI: 16.10–80.65) and procedure-related complications (RR: 8.52; 95% CI: 3.12–23.27). Side effects were significantly lower in the ablation group than in AAD therapy (RR: 0.04; 95% CI: 0.01–0.10). Conclusions Catheter ablation demonstrates superior efficacy in reducing arrhythmia recurrence and preventing progression to persistent AF, with a comparable safety profile to AAD therapy. However, the increased risk of reintervention and procedural complications highlights the need for careful patient selection and shared decision-making.