Ranking Efficacy of Three First–Line Treatments for Paroxysmal Atrial Fibrillation

Researchers compared the relative effectiveness of three first–line treatments for patients with paroxysmal atrial fibrillation (AF) using Bayesian probabilistic modelling of restricted mean survival time (RMST) based on a network meta–analysis. Lead author, Andrea Messori, MD, and colleagues from the Health Technology Assessment TA Unit and Ente Support Tecnico Amministrative of the Regional Health Service in Firenze, Italy, found that radiofrequency was the most effective treatment compared with cryoballoon ablation and medical treatment.


The report in Reviews in Cardiovascular Medicine specified that the two ablation techniques clearly performed better than medical therapy. Additionally, cryoballoon ablation and radiofrequency demonstrated no evidence of different efficacy in an indirect comparison based on data from the included randomized controlled trials (RCTs).


The investigators included five trials that assessed first–line treatments for paroxysmal AF. The primary outcome assessed was atrial fibrillation recurrence–free survival at 12 months. Comparisons between radiofrequency and cryoballoon ablation were indirect as no direct comparisons were made in RCTs.


Radiofrequency and cryoballoon ablation showed significantly increased effectiveness compared with medical treatment. In the indirect comparison, radiofrequency showed a non-significant advantage over cryoballoon ablation.


Dr. Messori further stated that, “as more follow-up accumulates, it will be worthwhile to update the analysis of these five RCTs based on a RMST milestone at more than 12 months. It should be noted that our study is one of the first examples where [network meta–analysis] has been combined with RMST as an outcome measure.”


Despite the limited data and inherent limitations of indirect comparisons and potential unidentified biases in their results, the authors stood by their rankings of the first-line paroxysmal AF treatments. They called for a prospective trial to further examine or directly compare the clinical efficacy of radiofrequency and cryoballoon ablation.