Antiarrhythmic drug therapy (ADT) and catheter ablation (CA) are the main treatments for paroxysmal atrial fibrillation. However, the short- and long-term clinical efficacy of these treatments remains controversial. Our goal is to investigate efficacy and safety of the standardized treatment of elderly patients with paroxysmal atrial fibrillation (PAF). Eight randomized controlled trials on CA and ADT for treating PAF were included. Totally, 1336 patients were included. Studies on CA and ADT for treating PAF that were published between January 2005 and June 2020 in the Cochrane Library, PubMed and EMBASE were screened and identified. Atrial fibrillation-free rates and Short Form (SF-36) health score-related indexes were analyzed. Atrial fibrillation-free rates were similar in the CA and ADT groups [risk ratio (RR) 1.32; 95% confidence interval (CI) 0.96-1.82; P = 0.08] at 3 months. The CA group had a significantly higher atrial fibrillation-free rate at 6 months (RR 1.87; 95% CI 1.38-2.53; P < 0.001), 9 months (RR 2.38; 95% CI 1.43-3.96; P < 0.001), and 12 months (RR 2.21; 95% CI 1.28-3.84; P = 0.005). However, there was no significant difference in terms of long-term efficacy at 24 months (RR 1.81; 95% CI 0.97-3.36; P = 0.06). The 12-month QOL physical and mental components (RR 2.41; 95% CI 0.89-3.93; P = 0.002) were significantly higher in CA group. The CA is more effective than ADT in the short-term prognosis. But the long-term prognosis of PAF needs to be verified via randomized controlled trials with longer follow-up durations.