First-line treatment of symptomatic paroxysmal atrial fibrillation (AF) with radiofrequency ablation (RFA) resulted in reduced occurrence and burden of AF at 5 years compared with antiarrhythmic drug (AAD) therapy. Jens Cosedis Nielsen, MD, PhD, Aarhus University, Aarhus, Denmark, presented 5-year follow-up data from the MANTRA-PAF [NCT00133211].

Over a 2-year period, there was no significant difference in AF, and improvements in quality of life were similar in patients with paroxysmal AF who received either RFA or AAD therapy [Nielsen JC et al. N Engl J Med. 2012]. The purpose of this analysis of the MANTRA-PAF trial was to evaluate the 5-year outcomes among patients who received first-line treatment with either RFA or AAD.

In the multicenter MANTRA-PAF trial, 294 patients with symptomatic paroxysmal AF were randomly assigned to undergo RFA or receive AAD. A 5-year follow-up was preplanned and included a 7-day Holter monitoring, quality of life assessment, AAD use, and RFA since 2-year follow-up. The mean age at baseline was 55 years, and 32% of patients had hypertension, 5% had diabetes mellitus, and 3% had a prior stroke or transient ischemic attack. The CHADS₂ score was 0 in 144 patients, 1 in 75 patients, and ≥ 2 in 26 patients.

At 5 years, the burden of AF was significantly lower in patients who underwent RFA compared with patients who received AAD (P = .003). In addition, treatment of AF with RFA resulted in a greater proportion of patients achieving freedom from any AF, freedom from symptomatic AF, and lower rates of persistent AF (Table 1). Overall, the burden of AF was lower with both therapies compared with baseline. However, there was no significant difference in the physical or mental components of quality of life at 5 years.

Patients in the AAD arm were significantly more likely to be taking a class Ic AAD at 5 years compared with the RFA arm (P = .001). In addition, slightly more patients in the AAD arm were taking a calcium-channel blocker or digoxin at 5 years compared with patients who underwent RFA. The proportion of patients taking a class III agent was similar among both arms.

Prof Nielsen concluded that the data from this 5-year follow-up of the MANTRA-PAF trial suggest that first-line treatment of AF with RFA led to improved outcomes with decreased occurrence and burden of symptomatic AF compared with patients who received AAD therapy. However, he acknowledged that there are currently no data that indicate RFA improves survival compared with AAD therapy, and the risk of severe complications associated with RFA must be considered when advising patients.