Pulmonary vein isolation has limited success in elderly patients with persistent atrial fibrillation, yet it remains the default offer. ABLATE versus PACE tested the alternative. Twelve centres in Germany and Austria randomised 196 patients aged 75 or over with symptomatic persistent AF and normal ejection fraction — median age 82 — to pacemaker implantation with AV-node ablation, or to PVI. The primary endpoint combined hospitalisation for atrial arrhythmia or heart failure, outpatient cardioversion, and upgrade to cardiac resynchronisation therapy.
At 12 months, 24 of 98 patients (24%) in the pace-and-ablate arm had a primary event against 45 of 98 (46%) after PVI (hazard ratio 0.45, 95% CI 0.27 to 0.74, p=0.002). The totals show where the difference came from: 84 events after PVI, mostly AF hospitalisations (54) and cardioversions (19), against 29 events after pace-and-ablate, mostly heart failure hospitalisations (23 versus 11). Complications, mortality and quality of life did not differ significantly.
Read that trade honestly. Pace-and-ablate does not abolish problems; it swaps one kind for another. The rhythm problem goes away by definition, and a heart failure problem partly takes its place, which is what you would expect from committing an 82-year-old to ventricular pacing. Quality of life ended up the same, so the case rests on hospitalisations and cardioversions avoided, not on how patients felt.
In Indian practice the relevant point is the framing rather than the device. Repeated cardioversions and repeat ablations in a very elderly patient with persistent AF are expensive, hard to travel for and often futile. A strategy that accepts AF and controls the ventricle deserves an explicit place in the conversation, alongside careful rate control on drugs, rather than being treated as a last resort after PVI has failed twice.
- In symptomatic persistent AF over 75, discuss pace-and-ablate as a first-line strategy rather than a salvage one.
- Set the expectation clearly: AF-related admissions fall, heart failure admissions rise somewhat.
- Quality of life was no better, so do not sell the strategy on symptoms alone.
- Consider the pacing mode carefully; conduction system pacing may mitigate the heart failure signal, though this trial does not answer that.
- Factor in travel and repeat-procedure burden, which weigh heavily against a low-yield PVI in this age group.
The statistics, in plain English
The hazard ratio of 0.45 with an interval of 0.27 to 0.74 is a clear result: the whole interval sits below 1.0. But the primary endpoint is a composite, and composites hide direction. Here two of its components moved in opposite ways — AF hospitalisations and cardioversions fell sharply, heart failure hospitalisations roughly doubled. The composite is positive because the first effect was larger, not because everything improved. With 196 patients, the trial had no power to detect differences in death or stroke, so 'no significant difference' in mortality means the question was not answered.
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