[Should we start with ablation or try a pill first? Is early cryoablation for atrial fibrillation really better?].

There is a worldwide trend towards earlier pulmonary vein isolation (PVI) in the treatment of atrial fibrillation (AF). Recently, the STOP-AF and EARLY-AF trials were published, comparing cryoablation and antiarrhythmic drugs as first line rhythm therapy for paroxysmal AF. Both studies did not show a difference in incidence of mortality or heart failure. The positive result was driven by a favorable difference of (mostly asymptomatic) recurrences, AF burden (which was also very low in the control groups) and a small improvement of Quality of Life. The clinical relevance of this outcome is limited. We advise to stick to the suggested steps in the guideline: evaluating the symptoms over a longer period of time, implementing lifestyle interventions and use medications for rate control, rhythm control if symptoms persist and for stroke prevention. If AF and symptoms persist ablation is an excellent treatment option with little risk.