Over 75 with persistent AF: pace-and-ablate halved the primary event rate compared with PVI

Design

Multicentre, open-label randomised trial

Population

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

Primary outcome

Arrhythmia or heart failure 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, an investigator-initiated open-label trial in the European Heart Journal (August 2026), randomised 196 patients aged 75 and over (median 82) with symptomatic persistent atrial fibrillation and normal left ventricular ejection fraction to pacemaker implantation with atrioventricular-node ablation, or pulmonary vein isolation (PVI), across 12 German and Austrian centres.

At 12 months the primary composite — hospitalisation for atrial arrhythmia or heart failure, outpatient cardioversion, or upgrade to resynchronisation therapy — occurred in 24% after pace-and-ablate and 46% after PVI (HR 0.45, 95% CI 0.27 to 0.74). The composition differed: PVI patients had 54 AF admissions and 19 cardioversions against 3 and 1; pace-and-ablate patients had 23 heart failure admissions against 11. Mortality, complications and quality of life did not differ.

The endpoint favours pace-and-ablate by design, since it largely counts events that AV-node ablation makes impossible. The rise in heart failure admissions is the signal to take seriously, and pacing mode matters — this trial did not mandate conduction-system pacing.

For the very elderly patient with persistent AF in whom rhythm control has limited prospects, pace-and-ablate is a legitimate first strategy rather than a last resort.

• Discuss pace-and-ablate as a first strategy for symptomatic persistent AF in patients over 75, not only after failed ablation
• Explain the trade: fewer AF admissions and cardioversions, but lifelong pacemaker dependence
• Consider conduction-system pacing to reduce the risk of pacing-induced heart failure
• Continue anticoagulation after AV-node ablation — stroke risk is unchanged
• Follow for heart failure symptoms after pace-and-ablate; admissions were twice as common

Why it matters

It challenges the habit of reaching for ablation in the very elderly, where rhythm control often fails and readmission is the real burden.

Don't overread it

The composite counts events AV-node ablation largely prevents by design; mortality and quality of life did not differ.

The statistics, in plain English

A hazard ratio of 0.45 means the rate of first primary events was less than half with pace-and-ablate, and the confidence interval (0.27 to 0.74) stays well below 1. But the heart failure component went the other way (23 vs 11 admissions), which the composite hides.

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