Effect of catheter ablation and pharmacotherapy on long‐term mortality in young patients with atrial fibrillation

BACKGROUND: Atrial fibrillation (AF) is becoming increasingly recognised in younger patients. While both anti-arrhythmic drug therapy and catheter ablation are recognised treatment options, their comparative effects on long-term mortality in younger patients are not known. AIMS: To describe an association between all-cause mortality, pharmacotherapy and pulmonary vein isolation in young patients with AF. METHODS: We conducted a retrospective observational cohort study using the Alfred Hospital's electronic medical records. Adults aged 18-65 at the time of first AF diagnosis were included and stratified into pharmacotherapy-led and catheter ablation-led groups. Inverse probability of treatment weighting was applied across a number of demographic and cardiometabolic covariates, achieving strict balance (standardised mean differences <0.1). All-cause mortality was evaluated using weighted Cox proportional hazards modelling and restricted mean survival time (RMST). RESULTS: The cohort comprised 1961 patients (1250 pharmacotherapy-led; 711 pulmonary vein isolation (PVI))-led. PVI-led was associated with a significant reduction in all-cause mortality compared with conservative medical therapy (adjusted hazard ratio (HR), 0.24; 95% CI: 0.10-0.59; P = 0.002) subject to significant residual confounding and selection bias. Over a 10-year RMST, the PVI-led strategy conferred an absolute survival benefit of 0.76 years. Neither strategy significantly reduced the risk of incident heart failure (adjusted HR 1.11; 95% CI: 0.58-2.11; P = 0.761). CONCLUSIONS: In younger patients and subject to significant residual confounding and selection bias, PVI was associated with significantly lower all-cause mortality than pharmacotherapy. These findings must only be considered hypothesis generating and require prospective validation.