Early Catheter Ablation for Patients With Atrial Fibrillation and a Stroke History

BACKGROUND AND OBJECTIVES: Atrial fibrillation (AF) is a major contributor to ischemic stroke, yet evidence on whether catheter ablation improves outcomes in patients with AF and a history of stroke remains limited. We emulated a target trial using observational data to estimate the effect of early catheter ablation vs medical therapy on clinical outcomes in this high-risk population. METHODS: We retrospectively included patients aged 18-85 years with AF and a history of ischemic stroke from 6 Chinese centers between January 2019 and December 2024. The primary outcome was major adverse cardiovascular events (MACEs). Secondary outcomes included all-cause rehospitalization, cardiovascular rehospitalization, all-cause death, and functional and cognitive outcomes assessed by modified Rankin Scale (mRS) and post hoc AD8 scores. A cloning-censoring-weighting approach was used to emulate a target trial comparing early ablation (within a 1-year grace period) and medical therapy in time-dependent outcomes, using weighted Kaplan-Meier curves. Restricted mean survival time (RMST) was used when the proportional hazards assumption was violated. mRS and AD8 were assessed after propensity score matching. RESULTS: = 0.002). DISCUSSION: In this target trial emulation analysis, catheter ablation was associated with a modestly lower long-term risk of MACE in patients with AF and a stroke history. Secondary analyses suggested exploratory associations between ablation and lower long-term cardiovascular rehospitalization, and better neurologic and cognitive outcomes. Major limitations include the retrospective design and potential residual confounding. Randomized trials with larger sample sizes are warranted. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that early catheter ablation in adult patients with AF and a history of ischemic stroke decreases the risk of MACEs compared with guideline-directed medical therapy.