Evaluating Atrial Fibrillation Treatments: A Hybrid Approach Emerges

A recent clinical trial conducted in Czechia sheds light on the ongoing debate surrounding the treatment of atrial fibrillation (AF), a condition that affects millions worldwide. The study, known as the PRAGUE-25 trial, evaluated whether a combination of lifestyle modifications and antiarrhythmic medications could match the efficacy of catheter ablation (CA) in maintaining sinus rhythm (SR) in patients with AF. The findings revealed that catheter ablation remains the superior method for achieving sustained freedom from AF, raising questions about optimal treatment strategies.

The PRAGUE-25 trial, published on July 24, 2025, randomized 212 patients with AF into two groups: one receiving catheter ablation alone and the other undergoing lifestyle modification alongside medication. After one year, 73% of patients in the ablation-only group achieved freedom from AF, compared to only 34.6% in the lifestyle modification group. These numbers shifted to 55.6% and 24.7%, respectively, by the two-year mark, underscoring the effectiveness of CA in rhythm control.

Dr. Sana Al-Khatib, an electrophysiologist at Duke University, emphasized the importance of a hybrid approach that combines both catheter ablation and lifestyle changes. She stated, 'You, of course, control the patient’s risk factors and also consider them for catheter ablation because we know it’s superior for rhythm control vs medication.' This perspective reflects a growing consensus among cardiologists that while CA is effective, the inclusion of lifestyle modifications can enhance patient outcomes.

Dr. Kenneth Ellenbogen, former president of the Heart Rhythm Society and an electrophysiologist at Virginia Commonwealth University, echoed these sentiments, noting that 'the take-home message for cardiologists should be that everyone can have risk factor modification — and catheter ablation. The patients who do both are going to do better than the patients who do one or the other.' His view aligns with findings from earlier studies, such as the 2015 LEGACY trial, which demonstrated that long-term weight management significantly reduces AF burden and contributes to maintaining sinus rhythm.

Moreover, the significance of maintaining sinus rhythm has been corroborated in various studies, including the CABANA trial, which indicated that patients in SR were 43% less likely to experience severe complications, such as death or stroke. According to Dr. Eric Prystowsky, a prominent cardiologist and director of the Cardiac Arrhythmia Service at Ascension St. Vincent Hospital, the evolution of treatment strategies has led to a paradigm shift favoring rhythm control over simple rate management. He highlighted that the 2002 AFFIRM trial initially set rate control as the preferred approach, but subsequent research has increasingly validated the benefits of rhythm control.

The recent guidelines from the American Heart Association and other organizations have also begun to reflect this shift. In their updated recommendations, released in 2023, they advocate for early rhythm control in AF management, emphasizing the need to minimize the burden of AF. Dr. Al-Khatib noted that this is crucial for reducing hospitalization rates and improving overall patient quality of life.

While catheter ablation is a powerful tool for rhythm control, it is not suitable for every patient. Dr. Prystowsky pointed out that older patients or those comfortable with living in AF may not be ideal candidates for the procedure. 'It’s not that everybody needs it, but the discussion and consideration of sinus rhythm is appropriate for every patient,' he stated. He also acknowledged the challenges associated with lifestyle modifications, particularly weight loss, which require structured programs for effective implementation.

Emerging treatments, such as GLP-1 agonists for weight loss, present new opportunities for managing AF in overweight patients. Dr. Prystowsky suggested that these medications could positively impact the metabolic processes related to AF, potentially reducing its occurrence.

In conclusion, the findings from the PRAGUE-25 trial reaffirm the critical role of catheter ablation in managing atrial fibrillation while simultaneously advocating for lifestyle modifications as a complementary strategy. As the medical community continues to refine its approach to AF treatment, the synthesis of these methods could lead to improved patient outcomes, particularly as clinicians prioritize maintaining sinus rhythm. The collective insights from leading experts underscore the necessity of a tailored approach to AF management, recognizing the complexity of the condition and the diverse needs of patients.