Abstract Body (Do not enter title and authors here): Background:
Although catheter ablation (CA) has become a cornerstone in rhythm control for atrial fibrillation (AF), real-world practice continues to lean heavily on antiarrhythmic drug (AAD) therapy, particularly in older, underserved, and racially diverse populations. While clinical trials demonstrated that ablation improves quality of life, symptom control, and long-term cardiovascular outcomes, these findings may not fully translate into routine care. This study examines nationwide patterns in the use of ablation and AADs, assess associated outcomes, and evaluate socio-demographic disparities in the treatment of AF.
Methods: A retrospective cohort study was done using the National Inpatient Sample (2016–2020), identifying adult hospitalizations with a primary diagnosis of AF. Treatment groups were defined as patients undergoing CA (ICD-10-PCS codes) and those receiving AADs. Outcomes included in-hospital mortality, length of stay, cardioversion rates, and major adverse events (stroke, cardiac arrest, bradyarrhythmia). Stratified analyses were performed by age, sex, race, insurance, and hospital type. Logistic regression models adjusted for clinical and demographic variables were used to identify predictors of treatment type and adverse outcomes.

Results:
Out of 287,450 weighted AF hospitalizations, only 6.7% underwent CA, while nearly 1/3 (32.8%) received AAD therapy. Ablation recipients were younger (mean age 61 vs. 72), more often male (63% vs. 52%), and White (76% vs. 59%). Patients from racial and ethnic minority groups, especially Black and Hispanic patients, were significantly less likely to receive ablation even after controlling for comorbidities and hospital characteristics. In-hospital mortality was markedly lower in the ablation group (0.3% vs. 1.9%), with fewer adverse events and shorter stays (median 2.1 vs. 4.3 days). Notably, adverse drug reactions and bradycardia were more frequent in the AAD group, particularly among women and older adults.

Conclusion:
Despite compelling evidence in favor of CA, real-world treatment for AF continues to favor pharmacologic rhythm control which affects women, racial minorities, and patients treated at small setups. Our findings suggest that rhythm control decisions are shaped not just by clinical factors, but also by systemic inequities in access and referral patterns. Reducing overreliance on AADs and expanding equitable access to ablation may improve patient outcomes and better align practice with evidence.