# EP Edge® × HRS: Rethinking the Defaults: AFib Ablation vs Antiarrhythmics, Flecainide Beyond CAST, and Physiologic Pacing

Page: https://stenobird.com/podcast/ep-edge-journal-watch-7561379/ep-edge-hrs-rethinking-the-defaults-afib-ablation-vs-antiarrhythmics-flecainide-beyond-cast-and-physiologic-pacing
Text version: https://stenobird.com/podcast/ep-edge-journal-watch-7561379/ep-edge-hrs-rethinking-the-defaults-afib-ablation-vs-antiarrhythmics-flecainide-beyond-cast-and-physiologic-pacing.md
Podcast: [EP Edge Journal Watch: Cardiac Electrophysiology Research](https://stenobird.com/podcast/ep-edge-journal-watch-7561379)
Published: 2026-08-31T09:30:00+00:00
Episode link: https://share.transistor.fm/s/022f07f4
Audio file: https://media.transistor.fm/022f07f4/d012204c.mp3
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JSON: https://stenobird.com/v1/public/podcasts/ep-edge-journal-watch-7561379/episodes/ep-edge-hrs-rethinking-the-defaults-afib-ablation-vs-antiarrhythmics-flecainide-beyond-cast-and-physiologic-pacing
Duration seconds: 2279

## Resource

In this EP Edge and Heart Rhythm Society collaborative podcast, Dr. Niraj Sharma and Dr. Mike Lloyd examine new evidence challenging several long-standing assumptions in cardiac electrophysiology: when to choose catheter ablation over antiarrhythmic drug therapy for atrial fibrillation, whether left bundle branch area pacing should replace conventional right ventricular pacing in patients who require substantial ventricular pacing, and how broadly the lessons of CAST should continue to restrict flecainide and other Class Ic antiarrhythmic drugs. The atrial fibrillation discussion brings together two complementary 2026 Heart Rhythm meta-analyses. Demy L. Idema and colleagues evaluated antiarrhythmic drugs versus catheter ablation for rhythm control across randomized controlled trials, focusing on AF recurrence, hospitalization, mortality, and treatment-related complications. Marwan Shawki and colleagues examined the safety of catheter ablation versus antiarrhythmic drugs across 24 randomized trials involving 6,665 participants. Together, the studies raise an important contemporary question: as ablation becomes more effective and procedural safety improves, does antiarrhythmic drug therapy still deserve an automatic position ahead of ablation in the AF treatment pathway? The discussion then turns to physiologic pacing and the PACE-HF trial by Jenish P. Shroff and colleagues, published in the European Heart Journal. In this prospective randomized trial, left bundle branch area pacing was compared with conventional right ventricular pacing in patients with preserved or mildly reduced left ventricular ejection fraction who were expected to require substantial ventricular pacing. The trial provides randomized evidence on ventricular function, pacing burden, heart failure hos…

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