Catheter ablation (CA) is established as more effective than antiarrhythmic drugs (AADs) for maintaining sinus rhythm in atrial fibrillation (AF), although safety comparisons have been limited by underpowered trials.

A systematic review and meta-analysis of randomized controlled trials (RCTs) published in the Heart Rhythm assessed complication rates and relative safety of CA versus AADs. MEDLINE, Embase, and Cochrane CENTRAL databases were searched from inception to October 24, 2024, to identify RCTs comparing CA with AADs in AF management.

A total of 24 RCTs comprising 6,665 participants were included, with 3,554 patients (53.2%) assigned to CA and 3,111 (46.7%) to AAD therapy. The primary endpoint was a composite of serious adverse events (SAE), including death, additional intervention, prolonged or unplanned hospitalization, or disability. 

Over a median follow-up of 12 months (range 6–60 months), CA was associated with a significantly lower risk of SAE compared with AADs (risk ratio [RR] 0.80; 95% confidence interval [CI] 0.69–0.93; P<0.01). CA also reduced the risk of unplanned hospitalization (RR 0.53; 95% CI 0.38–0.72; P<0.01) and adverse cardiovascular events (RR 0.63; 95% CI 0.44–0.90; P=0.01).
CA was associated with lower risks of serious complications and hospitalizations compared with AADs. AAD therapy demonstrated a comparatively less favorable safety profile in AF rhythm management.