Catheter Ablation vs Lifestyle Modification With Antiarrhythmic Drugs to Treat Atrial Fibrillation PRAGUE25 Trial summary

This PACULit episode reviews the PRAGUE-25 randomized multicenter noninferiority trial comparing catheter ablation with lifestyle modification plus guideline-directed antiarrhythmic drugs in adults with obesity (BMI 30–40) and paroxysmal or persistent atrial fibrillation. The ablation strategy focused on pulmonary vein isolation, while the lifestyle arm emphasized weight loss and physical activity paired with antiarrhythmic therapy. The primary endpoint—freedom from AF at 12 months (no episodes >30 seconds on a 7-day Holter)—favored ablation (73% vs 34.6%, p<0.001). Although the lifestyle-plus-drug approach achieved meaningful metabolic gains (average weight loss ~6.4 kg and HbA1c improvement), it did not translate into superior rhythm control. Follow-up averaged ~23.5 months with quarterly rhythm monitoring. The study supports catheter ablation as the preferred rhythm-control strategy in obese AF patients when rhythm suppression is the goal, while lifestyle modification remains important for metabolic risk reduction. Strengths include randomized multicenter design and objective rhythm monitoring; limitations include the 12-month primary endpoint and applicability to patients with more severe comorbidities.