Updated Meta-Analysis of Catheter Ablation Versus Medical Therapy in Atrial Fibrillation With Heart Failure With Preserved Ejection Fraction

Background: The advantage of catheter ablation compared to medical therapy for atrial fibrillation (AF) in patients diagnosed with heart failure with preserved ejection fraction (HFpEF) remains indeterminate. A meta-analysis was conducted to assess outcomes within this population. Methods: We searched MEDLINE, Embase, Cochrane CENTRAL, and ClinicalTrials.gov through May 2025. Twelve studies satisfied the inclusion criteria, encompassing a total sample size of 43 584 individuals. Outcomes included primary composite endpoints, HF hospitalizations, all-cause mortality, AF recurrence, cardiovascular (CV) mortality, all-cause hospitalization, and stroke. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using random-effects models; heterogeneity was assessed using I² statistics. Publication bias and sensitivity analyses were also performed. Results: Catheter ablation notably reduced the primary composite endpoint (HR, 0.53; 95% CI, 0.41–0.68; p < 0.01) and hospitalizations due to heart failure (HR, 0.62; 95% CI, 0.48–0.81; p < 0.01). The overall mortality rate was reduced with ablation (HR, 0.64; 95% CI, 0.45–0.91; p < 0.01). A trend toward lower atrial fibrillation recurrence was observed (HR 0.64; 95% CI 0.38–1.10). The intervention significantly decreased the risk of stroke (HR, 0.66; 95% CI, 0.60–0.72; p < 0.01). Other outcomes indicated a favorable effect of ablation; however, they did not attain statistical significance. Conclusion: In patients with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF), catheter ablation is correlated with substantially enhanced outcomes compared to medical therapy, particularly in decreasing composite events, mortality, and the incidence of stroke. Trial Registration: PROSPERO (CRD420251069889).