A minimally invasive heart procedure may be a better first-line treatment than medication for people living with advanced forms of atrial fibrillation, according to a major international clinical trial led by researchers at the University of British Columbia.
Atrial fibrillation (AFib) is a common and serious heart rhythm disorder that affects more than 50 million people worldwide, including about one million Canadians. It causes the heart to beat irregularly, which can lead to symptoms like fatigue, shortness of breath and palpitations, and significantly increases the risk of stroke, heart failure and early death.
For decades, most patients with AFib have been treated with medications first. Procedures like catheter ablation—a minimally invasive technique used to correct faulty electrical signalling in the heart—have typically been reserved for patients whose symptoms persist despite drug therapy. While recent research has suggested ablation may be a more effective initial treatment for early-stage disease, it has also been unclear whether this is true for patients with more advanced disease, who tend to be older, have more underlying health conditions and face higher risks overall.
Published in the New England Journal of Medicine , the new study shows starting with ablation can lead to better outcomes for patients with advanced forms of AFib.
"Traditionally, we've taken a stepwise approach, starting with medications and moving to procedures later," said Dr. Jason Andrade , clinical professor at UBC's faculty of medicine and investigator at the Centre for Cardiovascular Innovation. "What this trial shows is that, even in patients with more advanced AFib, earlier intervention with ablation can provide substantial benefits and better control of the disease."
A different way to treat the heart
The study focused on patients with persistent AFib, a more serious form in which the abnormal rhythm lasts longer and is more difficult to treat.
Researchers randomly assigned patients to receive either catheter ablation as their initial treatment or standard anti-arrhythmic drug therapy.
During catheter ablation, physicians guide thin, flexible tubes through blood vessels into the heart. Once in place, they eliminate the areas of heart tissue responsible for triggering and sustaining the abnormal electrical signals.
In this study, researchers used a newer technique called pulsed field ablation, which delivers short bursts of electrical energy to precisely target heart tissue.
"You can think of it as resetting the heart's electrical system," said Dr. Andrade. "Instead of using heat or freezing, this approach uses carefully controlled pulses to interrupt abnormal signals while minimizing damage to surrounding tissue."
After one year, patients who underwent ablation were significantly more likely to remain free of abnormal heart rhythms than those who started with medication. The overall risk of serious adverse events was similar between the two groups.
"Patients with more advanced atrial fibrillation are inherently more complex," said Dr. Andrade. "Even in this higher-risk group, starting with ablation can offer better control of the condition."
A decade of reshaping global care
The findings build on more than a decade of research led by Dr. Andrade and his team that has helped transform how AFib is treated worldwide.
Earlier landmark trials from this group demonstrated that catheter ablation could be used as a first-line treatment in patients with early-stage AFib. In addition, these studies were the first to demonstrate that catheter ablation was a disease-modifying therapy, significantly slowing the progression of the disease.
Those discoveries helped shift clinical practice globally, with physicians increasingly offering ablation earlier in a patient's care.
Together, the program of research has redefined how AFib can be treated across its full course—from early to more advanced stages—giving patients and clinicians clearer guidance on when to consider ablation.
"Our goal is to give patients and clinicians the evidence they need to make the best decision for each individual," said Dr. Andrade. "This study fills an important gap for a group of patients where the answer hasn't been clear."
