Over-75s with persistent AF: pace-and-ablate halved the admission and cardioversion endpoint against PVI

Design

Multicentre, randomised, open-label trial

Population

196 patients aged ≥75 (median 82) with symptomatic persistent AF and normal LVEF

Primary outcome

Arrhythmia or HF admission, cardioversion or CRT upgrade at 12 months

Effect

24% vs 46%, HR 0.45 (95% CI 0.27 to 0.74)

ABLATE versus PACE randomised 196 patients aged 75 or over (median 82) with symptomatic persistent AF and normal left ventricular ejection fraction, at 12 centres in Germany and Austria, to pacemaker implantation with atrioventricular-node ablation or to pulmonary vein isolation. The trial was open-label.

At 12 months, the composite of admission for arrhythmia or heart failure, outpatient cardioversion or upgrade to cardiac resynchronisation occurred in 24% after pace-and-ablate and 46% after PVI (HR 0.45, 0.27 to 0.74). PVI patients had 54 AF admissions and 19 cardioversions, against 3 and 1. But heart failure admissions went the other way, 23 against 11. Complications, mortality and quality of life did not differ.

In the very elderly, PVI is often chosen because it seems less final. This trial shows a strategy of rate control by ablation gave fewer repeat procedures and admissions, at the cost of pacing dependence and more heart failure admissions. The heart failure signal matters: conduction-system pacing rather than right ventricular pacing may reduce it, and is worth considering.

• Discuss pace-and-ablate as a first option with symptomatic over-75s with persistent AF
• Explain lifelong pacemaker dependence before choosing it
• Prefer conduction-system or biventricular pacing where available to limit heart failure
• Monitor for heart failure symptoms after pace-and-ablate
• Continue anticoagulation whichever strategy is chosen

Why it matters

It challenges the reflex to offer PVI first to the very elderly, where it mostly buys repeat admissions.

Don't overread it

Follow-up was one year, the trial was open-label and small, and heart failure admissions were more frequent after pace-and-ablate.

The statistics, in plain English

A hazard ratio of 0.45 means the rate of a first endpoint event was less than half, and the interval (0.27 to 0.74) is well clear of 1. But a composite can hide opposing parts: fewer AF admissions and cardioversions after pace-and-ablate, more heart failure admissions. Open-label design matters here, because the decision to admit or cardiovert can be influenced by knowing the treatment.

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