SMALL STUDY FINDS ABLATION DOES NOT IMPROVE OUTCOMES IN PATIENTS WITH ATRIAL FIBRILLATION AND RECENT STROKE
March 2026
Catheter ablation has become a widely used treatment for atrial fibrillation (AF) and is more effective than antiarrhythmic drugs at preventing AF recurrence. Guidelines support ablation in patients with drug-resistant, symptomatic paroxysmal or persistent AF, and early rhythm control—including with ablation—is recommended in select patients. Whether adding ablation to anticoagulation improves hard clinical outcomes (e.g., recurrent stroke, death, heart failure) in high-risk groups, such as patients with a recent stroke, is uncertain.
The Stroke Secondary Prevention With Catheter Ablation and Edoxaban for Patients With Nonvalvular Atrial Fibrillation (STABLED) study was an open-label, parallel-group, randomized trial conducted at 45 sites in Japan. It enrolled 251 adults with nonvalvular AF and a history of ischemic stroke within the previous 6 months who were on or scheduled to receive edoxaban; 249 were randomized (124 to edoxaban alone, 125 to edoxaban plus catheter ablation). Ablation was performed after at least 4 weeks of edoxaban and within 1 to 6 months of the index stroke. Median follow-up was about 3.5 years. At the end of the trial, the primary endpoint, a composite of recurrent ischemic stroke, systemic embolism, all-cause death, and hospitalization for heart failure, occurred in 18% of patients in both groups (HR 1.11; 95% CI 0.62–2.01; P=0.70). Crossover rates were similar across groups: 16 (12.9%) of those assigned to standard therapy crossed over to ablation, and 19 (15.2%) assigned to ablation did not receive the procedure. In the ablation group, 17.0% of patients underwent repeat ablation, including one patient who had three procedures. Two ablation-related serious adverse events were reported (one cardiac tamponade and one stroke).
STABLED was a small trial with fewer primary events than anticipated, leading to insufficient power and wide confidence intervals. Ablation has been shown to improve outcomes in patients with heart failure with reduced ejection fraction (e.g., CASTLE-AF, CASTLE-HTx). However, studies in broader populations have not shown a clear benefit. The large CABANA trial (N=2204) comparing catheter ablation to antiarrhythmic drugs did not find that ablation improved CVD outcomes. For patients with AF and a recent stroke, STABLED does not support routine ablation for secondary stroke prevention. Larger trials are needed to clarify the role of ablation in patients without significant heart failure.
