Twelve centres in Germany and Austria randomised 196 patients aged 75 or over with symptomatic persistent atrial fibrillation and a normal ejection fraction to one of two strategies: pacemaker implantation with atrioventricular-node ablation, or pulmonary vein isolation. Median age was 82. The primary endpoint was a composite of admission for atrial arrhythmia or heart failure, outpatient cardioversion, or upgrade to cardiac resynchronisation therapy.
At twelve months a first primary event had occurred in 24 of 98 patients assigned to pace-and-ablate and 45 of 98 assigned to ablation, a hazard ratio of 0.45 with a confidence interval from 0.27 to 0.74. Counting all events rather than first events widens the gap: 29 against 84.
What matters clinically is that the two arms failed differently. The ablation group came back with atrial fibrillation admissions and cardioversions — 54 and 19 events respectively, against 3 and 1 in the pace-and-ablate arm. The pace-and-ablate group came back with heart failure admissions, 23 against 11. So the composite is not one strategy being better at everything; it is a trade of arrhythmia recurrence for heart failure risk, and in this elderly cohort that trade came out favourably. Mortality, cardiovascular complications and quality of life did not differ.
- Applies to age 75 and over with persistent atrial fibrillation and preserved ejection fraction
- The comparison is a strategy, not a procedure — both arms received further treatment as needed
- Pace-and-ablate is irreversible and pacemaker-dependent; that conversation belongs before consent
- Heart failure admissions doubled in the pace-and-ablate arm, which is the cost of the trade
- Open-label, so the softer endpoints such as cardioversion carry more judgement than the hard ones
The statistics, in plain English
A hazard ratio of 0.45 means events accrued at roughly 45% of the rate in the ablation arm; the interval of 0.27 to 0.74 sits well below 1.0, so the direction is secure even though the trial is small. With 196 patients, the estimate of how large the benefit is remains loose — the true value could plausibly be a 73% reduction or a 26% one. Open-label design matters most for the endpoints a clinician decides on, such as elective cardioversion, and least for admissions.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for cardiology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free