Rhythm Control of Persistent Atrial Fibrillation in Systolic Heart Failure: A Bayesian Network Meta-Analysis of...

Persistent atrial fibrillation (PeAF) with heart failure (HF) arguably constitutes the sickest subset of atrial fibrillation (AF) patients.

A systematic search was made in PubMed, Embase, and Scopus databases. Network meta-analysis (NMA) of PeAF patients with systolic HF comparing all-cause mortality, change in HF-related quality of life (QoL) and hospitalization due to heart failure (HHF) were performed among catheter ablation (CA) of AF, rate-controlling drugs (RCDs), anti-arrhythmic drugs (AADs), and atrio-ventricular nodal ablation (AVNA) using Bayesian random effect model.

Ablation strategies resulted significantly lower mortality than medical therapies (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.35 to 0.76). CA of AF was associated with lower trend of mortality (OR, 0.78; 95% credible interval [CrI], 0.08 to 7.63) in comparison to AVNA in the Bayesian NMA. Rhythm control strategies resulted significantly higher improvement of QoL than rate control strategies (mean difference [MD], -12.78; 95% CI, -21.26 to -4.31). Bayesian NMA showed that CA of AF was better than AAD (MD, -7.98; 95% CrI, -27.68 to 8.27), however ranked AVNA to be lowest. Ablation strategies provided significantly lower HHF than medical therapies (OR, 0.42; 95% CI, 0.30 to 0.58). Bayesian NMA showed that CA of AF performed not only better than AAD (OR, 0.33; 95% CrI, 0.09 to 1.3) to reduce HHF, but also than AVNA (OR, 0.20; 95% CrI, 0.00 to 4.76). Of note, RCD ranked lowest with regard to mortality and HHF.

CA of AF remains the best strategy even for the sickest group of PeAF patients with systolic HF in regards to all-cause mortality, HF-related QoL and HHF.