Population Health Research Institute, Hamilton, Ontario, Canada.
Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
JAMA Cardiol. 2024 Jun 1;9(6):545-555. doi: 10.1001/jamacardio.2024.0675.
Catheter ablation is associated with reduced heart failure (HF) hospitalization and death in select patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). However, the benefit in patients with HF with preserved ejection fraction (HFpEF) is uncertain.
To investigate whether catheter ablation for AF is associated with reduced HF-related outcomes according to HF phenotype.
A systematic search of MEDLINE, Embase, and Cochrane Central was conducted among studies published from inception to September 2023.
Parallel-group randomized clinical trials (RCTs) comparing catheter ablation with conventional rate or rhythm control therapies in patients with HF, New York Heart Association functional class II or greater, and a history of paroxysmal or persistent AF were included. Pairs of independent reviewers screened 7531 titles and abstracts, of which 12 RCTs and 4 substudies met selection criteria.
Data were abstracted in duplicate according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Pooled effect estimates were calculated using random-effects Mantel-Haenszel models. Interaction P values were used to test for subgroup differences.
The primary outcome was HF events, defined as HF hospitalization, clinically significant worsening of HF, or unscheduled visits to a clinician for treatment intensification. Secondary outcomes included cardiovascular and all-cause mortality.
A total of 12 RCTs with 2465 participants (mean [SD] age, 65.3 [9.7] years; 658 females [26.7%]) were included; there were 1552 participants with HFrEF and 913 participants with HFpEF. Compared with conventional rate or rhythm control, catheter ablation was associated with reduced risk of HF events in HFrEF (risk ratio [RR], 0.59; 95% CI, 0.48-0.72), while there was no benefit in patients with HFpEF (RR, 0.93; 95% CI, 0.65-1.32) (P for interaction = .03). Catheter ablation was associated with reduced risk of cardiovascular death compared with conventional therapies in HFrEF (RR, 0.49; 95% CI, 0.34-0.70) but a differential association was not detected in HFpEF (RR, 0.91; 95% CI, 0.46-1.79) (P for interaction = .12). Similarly, no difference in the association of catheter ablation with all-cause mortality was found between HFrEF (RR vs conventional therapies, 0.63; 95% CI, 0.47-0.86) and HFpEF (RR vs conventional therapies, 0.95; 95% CI, 0.39-2.30) groups (P for interaction = .39).
This study found that catheter ablation for AF was associated with reduced risk of HF events in patients with HFrEF but had limited or no benefit in HFpEF. Results from ongoing trials may further elucidate the role of catheter ablation for AF in HFpEF.
在某些选择的心房颤动（AF）和射血分数降低的心力衰竭（HFrEF）患者中，导管消融术与心力衰竭（HF）住院和死亡风险降低相关。然而，HF 射血分数保留（HFpEF）患者的获益尚不确定。
研究根据 HF 表型，导管消融术治疗 AF 是否与减少 HF 相关结局有关。
系统检索了从开始到 2023 年 9 月发表的 MEDLINE、Embase 和 Cochrane 中央数据库中的研究。
纳入了比较导管消融术与 HF、纽约心脏协会功能分级 II 级或更高、有阵发性或持续性 AF 病史的患者的常规速率或节律控制治疗的平行组随机临床试验（RCT）。两名独立评审员对 7531 篇标题和摘要进行了筛选，其中 12 项 RCT 和 4 项亚研究符合入选标准。
根据系统评价和荟萃分析的首选报告项目（PRISMA）报告准则，对数据进行了重复提取。使用随机效应曼-惠特尼模型计算汇总效应估计值。交互 P 值用于检验亚组差异。
主要结局为 HF 事件，定义为 HF 住院、HF 明显恶化或因治疗强化而未预约就诊的临床医生。次要结局包括心血管和全因死亡率。
共纳入了 12 项 RCT 和 2465 名参与者（平均[标准差]年龄 65.3[9.7]岁；658 名女性[26.7%]）；其中 1552 名参与者患有 HFrEF，913 名参与者患有 HFpEF。与常规速率或节律控制相比，导管消融术与 HFrEF 患者 HF 事件风险降低相关（风险比 [RR]，0.59；95%CI，0.48-0.72），而在 HFpEF 患者中没有获益（RR，0.93；95%CI，0.65-1.32）（P 交互 = .03）。与常规疗法相比，导管消融术与 HFrEF 患者的心血管死亡风险降低相关（RR，0.49；95%CI，0.34-0.70），但在 HFpEF 中未检测到差异关联（RR，0.91；95%CI，0.46-1.79）（P 交互 = .12）。同样，在 HFrEF （RR 与常规疗法相比，0.63；95%CI，0.47-0.86）和 HFpEF （RR 与常规疗法相比，0.95；95%CI，0.39-2.30）组中，导管消融术与全因死亡率的相关性无差异（P 交互 = .39）。
本研究发现，在 HFrEF 患者中，导管消融术治疗 AF 与 HF 事件风险降低相关，但在 HFpEF 中获益有限或没有获益。正在进行的试验的结果可能会进一步阐明导管消融术在 HFpEF 中的作用。
