The edition · Cardiology
In patients over 75 with persistent AF, pace-and-ablate halved the hospital-and-cardioversion endpoint against PVI
ABLATE versus PACE favours the older strategy, 28 trials support intracoronary imaging again, a patient-level analysis sharpens AF-PCI antithrombotic choice, and early evolocumab after MI lowered LDL without a one-year clinical gain.
The edition in brief
In ABLATE versus PACE, 196 patients aged 75 or over (median 82) with symptomatic persistent AF and normal ejection fraction were randomised to pacemaker plus atrioventricular-node ablation or pulmonary vein isolation. At 12 months the composite of arrhythmia or heart failure admission, cardioversion or CRT upgrade occurred in 24% against 46% (HR 0.45, 0.27 to 0.74), driven by fewer AF admissions and cardioversions, though heart failure admissions were higher after pace-and-ablate. An updated meta-analysis of 28 randomised trials (24,634 patients) found intracoronary imaging-guided PCI associated with lower target lesion failure (RR 0.72), cardiac death (0.73), stent thrombosis (0.55) and all-cause death (0.82) against angiography guidance. A patient-level network meta-analysis of six AF-PCI trials (10,634 patients) found no difference in death, MI or stroke across strategies at one year, but DOAC plus a P2Y12 inhibitor halved TIMI major bleeding against VKA plus DAPT (HR 0.48) and cut intracranial haemorrhage (0.21); early MI and stent thrombosis were higher in the first 14 days with single antiplatelet strategies. In AMUNDSEN, evolocumab started before PCI for high-risk MI brought 82% to target LDL against 40%, but death or cardiovascular admission at one year did not differ (14.6% vs 15.4%). In PIFPAF-PFA, adding posterior wall isolation to pulsed field PVI did not significantly reduce recurrence (50.6% vs 60.6%, RR 0.75, 0.51 to 1.09).
Intracoronary imaging-guided PCI: 28 trials point to lower cardiac death and stent thrombosis
Use intracoronary imaging for complex and left main PCI; the pooled trial evidence still favours it on hard outcomes.
AF after PCI: a DOAC plus P2Y12 inhibitor halved major bleeding without a clear ischaemic cost at one year
After PCI in AF, use a DOAC plus P2Y12 inhibitor, and keep aspirin briefly only when early stent thrombosis risk is high.
Evolocumab before PCI for high-risk MI reached LDL targets but did not reduce events at one year
Start intensive lipid lowering early after MI and escalate on the 6-week LDL; there is no need to give a PCSK9 inhibitor in the catheter laboratory.
Adding posterior wall isolation to pulsed field PVI did not significantly reduce persistent AF recurrence
Keep PVI alone as the standard first ablation for persistent AF; posterior wall isolation is not proven to add benefit.
Write the stop date for each antithrombotic on the discharge summary
On discharge after PCI in AF, write a stop date against every antithrombotic drug.
Over-75s with persistent AF: pace-and-ablate halved the admission and cardioversion endpoint against PVI
For symptomatic persistent AF over 75, offer pace-and-ablate alongside PVI as a first-line option, and watch for heart failure afterwards.
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