Aggressive Risk Factor Reduction Study for Atrial Fibrillation and Implications for the Outcome of Ablation
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Background The long-term outcome of atrial fibrillation (AF) ablation demonstrates attrition. This outcome may be due to failure to attenuate the progressive substrate promoted by cardiovascular risk factors.Objectives The goal of this study was to evaluate the impact of risk factor and weight management on AF ablation outcomes.Methods Of 281 consecutive patients undergoing AF ablation, 149 with a body mass index ≥27 kg/m(2) and ≥1 cardiac risk factor were offered risk factor management (RFM) according to American Heart Association/American College of Cardiology guidelines. After AF ablation, all 61 patients who opted for RFM and 88 control subjects were assessed every 3 to 6 months by clinic review and 7-day Holter monitoring. Changes in the Atrial Fibrillation Severity Scale scores were determined.Results There were no differences in baseline characteristics, number of procedures, or follow-up duration between the groups (p = NS). RFM resulted in greater reductions in weight (p = 0.002) and blood pressure (p = 0.006), and better glycemic control (p = 0.001) and lipid profiles (p = 0.01). At follow-up, AF frequency, duration, symptoms, and symptom severity decreased more in the RFM group compared with the control group (all p < 0.001). Single-procedure drug-unassisted arrhythmia-free survival was greater in RFM patients compared with control subjects (p < 0.001). Multiple-procedure arrhythmia-free survival was markedly better in RFM patients compared with control subjects (p < 0.001), with 16% and 42.4%, respectively, using antiarrhythmic drugs (p = 0.004). On multivariate analysis, type of AF (p < 0.001) and RFM (hazard ratio 4.8 [95% confidence interval: 2.04 to 11.4]; p < 0.001) were independent predictors of arrhythmia-free survival.Conclusions Aggressive RFM improved the long-term success of AF ablation. This study underscores the importance of therapy directed at the primary promoters of the AF substrate to facilitate rhythm control strategies.
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Moderate or severe OSA (AHI ≥15) is reported in 20%-62% of atrial fibrillation patients.
“Moderate or severe OSA (AHI ≥ 15) is reported in 20%–62%.330,704,706,710–715”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [330]
Table 1 (Baseline Characteristics; page unavailable) reports AHI >30 in 55 of 88 control patients (62%) undergoing AF ablation. This supports an upper-end figure in a selected group, but the paper does not report a 20%–62% range for moderate or severe OSA defined as AHI ≥15 among AF patients generally. (LLM, conf=0.87)
Experimental — accuracy not yet measuredIn studies such as the ARREST-AF cohort study or the ACTIVE-AF trial, regular exercise programs exhibited a reduction in AF-related symptoms, AF incidence, and AF recurrence rates.
“In studies, such as the ARREST-AF cohort study or the ACTIVE-AF trial, regular exercise programs exhibited a reduction in AF-related symptoms, AF incidence, and AF recurrence rates [76,77].”
From Atrial Fibrillation in Elite Athletes: A Comprehensive Review of the Literature (2024) · cites this paper as [76]
The intervention description (section labeled CONCLUSIONS; page unavailable) includes prescribed regular exercise as part of a broader risk-factor and weight-management program. The ATRIAL FIBRILLATION results report greater reductions in symptoms and recurrence after ablation in the management group. The study did not isolate exercise’s effect or assess new AF incidence: participants already had symptomatic AF. (LLM, conf=0.87)
Experimental — accuracy not yet measuredOther studies of subjective or objective tonsil evaluation and AHI reported a trend toward significance or a significant association.
“Other groups have studied the relationship between subjective (grade) or objective (volume/weight) tonsil evaluation and AHI and reported a trend toward significance328 or a significant association.318,329–334”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [330]
The sleep-disordered breathing passage (section labeled CONCLUSIONS; page unavailable) describes how AHI was measured and used to offer treatment, but says nothing about tonsil evaluation. Searches for tonsil grade, volume, weight, and tonsillar hypertrophy found no passage assessing their association with AHI. (LLM, conf=0.76)
Experimental — accuracy not yet measuredAtrial fibrillation occurs at a high incidence after cavotricuspid isthmus ablation for typical atrial flutter.
“Given the high incidence of AF after CTI ablation for typical AFL”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [166]
Intensive weight-reduction management in addition to management of other cardiovascular risk factors (in the range of 10-15 kg weight loss achieved) led to fewer AF recurrences and symptoms compared with an approach based on general advice in obese patients with AF.
“Intensive weight-reduction management in addition to management of other cardiovascular risk factors (in the range of 10-15 kg weight loss achieved) led to fewer AF recurrences and symptoms compared with an approach based on general advice in obese patients with AF.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [203]
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“triggers.(301,343) A recent observational study demonstrated a lower AF ablation success rate in moderate and heavy drinkers.”
BackgroundSelf-citationLong-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort
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2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation
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Self-citationEpicardial adipose tissue in contemporary cardiology
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“Recent preliminary studies have suggested that aggressive treatment of hypertension improves post-ablation outcomes.(200,464,465)”
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“Recent preliminary studies have suggested that aggressive treatment of hypertension improves post-ablation outcomes.(200,464,465)”
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Self-citationAtrial Fibrillation and Mechanisms of Stroke: Time for a New Model
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“Intensive vascular risk factor management after AF ablation appears to improve the underlying atrial substrate.(50) Therefore, future trials may be warranted to assess whether treatment of atrial substrate reduces stroke risk.”
Modifiable Risk Factors and Atrial Fibrillation
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2021 ESC Guidelines on cardiovascular disease prevention in clinical practice
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“The AFSS has been clinically validated and used for assessment of AF burden (5,16).”
BackgroundMethodChung, M. K., Eckhardt, L. L., Chen, L. Y., Ahmed, H. M., Gopinathannair, R., Joglar, J. A., Noseworthy, P. A., Pack, Q. R., Sanders, P., & Trulock, K. M. (2020) · Circulation · doi:10.1161/cir.0000000000000748 · Cited by 549 · see citing works
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Obesity and Atrial Fibrillation Prevalence, Pathogenesis, and Prognosis
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“The mechanism underlying the favorable impact of weight loss on AF related outcomes are related to both indirect effects on CVD risk factors and direct effects on cardiac structure and function (73,80,81).”
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“Nt-proBNP (ng/mL) 59 (35, 100) 37 (20, 76) <0.”
Heart Failure With Preserved Ejection Fraction and Atrial Fibrillation
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Alcohol Abstinence in Drinkers with Atrial Fibrillation
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“intensive vascular risk factor management after catheter ablation of AF compared with those who received usual care.(127)”
MethodLinz, D., McEvoy, R. D., Cowie, M. R., Somers, V. K., Nattel, S., Lévy, P., Kalman, J. M., & Sanders, P. (2018) · JAMA Cardiology · doi:10.1001/jamacardio.2018.0095 · Cited by 411 · see citing works
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Left Atrial Reverse Remodeling
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“dietary modification and increased physical activity with consequent weight loss has been shown to improve blood pressure control in at-risk patients with paroxysmal AF (122,123).”
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Epidemiology and modifiable risk factors for atrial fibrillation
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International Consensus Statement on Obstructive Sleep Apnea
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Obesity and the Risk of Incident, Post-Operative, and Post-Ablation Atrial Fibrillation
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“In addition, in patients undergoing catheter ablation, aggressive management of risk factors has been associated with a significantly greater chance of remaining in sinus rhythm [99].”
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Alcohol and Atrial Fibrillation
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“Obesity is a powerful determinant of left atrial (LA) size and a well-recognized modifiable AF risk factor (54).”
BackgroundInfluentialSelf-citationGenetic Predisposition, Clinical Risk Factor Burden, and Lifetime Risk of Atrial Fibrillation
Weng, L.-C. C., Preis, S. R., Hulme, O. L., Larson, M. G., Choi, S. H., Wang, B., Trinquart, L., McManus, D. D., Stærk, L., Lin, H., et al. (2017) · Circulation · doi:10.1161/circulationaha.117.031431 · Cited by 271 · see citing works
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Hypertension and Atrial Fibrillation
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“glycemic control, smoking and alcohol control, and sleepdisordered breathing control.(155) Overall, 69 of these patients”
BackgroundCatheter ablation for atrial fibrillation: current indications and evolving technologies
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Self-citationExercise for Primary and Secondary Prevention of Cardiovascular Disease
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Evaluating the Atrial Myopathy Underlying Atrial Fibrillation
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The role of obesity in atrial fibrillation
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“ARREST-AF cohort Pathak et al.(44) 149 obese AF patients with ≥1 cardiac risk factor having ablation were offered RFM.”
Self-citationAndrade, J. G., Verma, A., Mitchell, L. B., Parkash, R., Leblanc, K., Atzema, C. L., Healey, J. S., Bell, A., Cairns, J. A., Connolly, S. J., et al. (2018) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2018.08.026 · Cited by 235 · see citing works
Associations of Epicardial, Abdominal, and Overall Adiposity With Atrial Fibrillation
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Self-citation2020 Clinical guidelines for Atrial fibrillation and atrial flutter
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“Risk factor intervention can prevent AF recurrence (46), improve arrhythmic outcomes after ablation (46,47), and may have efficacy comparable to repeat ablation in response to AF recurrence after an initial ablation procedure (48).”
BackgroundCalkins, H. G., Hindricks, G., Cappato, R., Kim, Y., Saad, E., Aguinaga, L., Akar, J. G., Badhwar, V., Brugada, J., Camm, A. J., et al. (2017) · Heart Rhythm · doi:10.1016/j.hrthm.2017.07.009 · Cited by 225 · see citing works
Self-citationFibrotic Atrial Cardiomyopathy, Atrial Fibrillation, and Thromboembolism
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“Among obese patients with AF undergoing ablation procedures, lifestyle changes resulting in weight loss, lower blood pressure, and better glycemic control were associated with more successful rhythm control, and reduction in epicardial adiposity was implicated (67).”
BackgroundComorbidity of atrial fibrillation and heart failure
Ling, L., Kistler, P. M., Kalman, J. M., SCHILLING, R. J., & Hunter, R. J. (2015) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2015.191 · Cited by 213 · see citing works
Self-citationSleep Apnea and Cardiovascular Disease: An Enigmatic Risk Factor
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JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias
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“and Implications for the Outcome of Ablation (ARREST-AF) study.(19) Despite the evidence for risk factor management, it has been demonstrated previously that the minority of AF patients receive guideline-recommended therapies for their comorbid cardiovascular conditions, with nearly 60% of AF”
BackgroundIntegrated care in atrial fibrillation: a systematic review and meta-analysis
Gallagher, C., Elliott, A. D., Wong, C. X. J., Rangnekar, G., Middeldorp, M. E., Mahajan, R., Lau, D. H., Sanders, P., & Hendriks, J. (2017) · Heart · doi:10.1136/heartjnl-2016-310952 · Cited by 198 · see citing works
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Self-citationKatritsis, D. G., Boriani, G., Cosio, F. G., Hindricks, G., Jaïs, P., Josephson, M. E., Keegan, R., Kim, Y.-H., Knight, B. P., Kuck, K.-H., et al. (2017) · Europace · doi:10.1093/europace/euw301 · Cited by 188 · see citing works
Obstructive Sleep Apnea: A Cluster Analysis at Time of Diagnosis
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“A recent study has demonstrated that aggressive multimodal risk factor management including OSA treatment improved the long-term success of atrial fibrillation ablation [26].”
BackgroundCare Patterns and Outcomes in Atrial Fibrillation Patients With and Without Diabetes
Echouffo-Tcheugui, J. B., Shrader, P. J., Thomas, L. E., Gersh, B. J., Kowey, P. R., Mahaffey, K. W., Singer, D. E., Hylek, E. M., Go, A. S., Peterson, E. D., et al. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2017.07.755 · Cited by 180 · see citing works
“However, the ARREST-AF (Aggressive Risk Factor Reduction Study for Atrial Fibrillation and Implications for the Outcome of Ablation) trial suggested that this may be the case, as it showed that a strategy of aggressive modification of several risk factors, including weight loss and improved glycemic control, was assoc…”
MethodAtrial Cardiopathy: A Broadened Concept of Left Atrial Thromboembolism Beyond Atrial Fibrillation
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Novel mechanisms in the pathogenesis of atrial fibrillation: practical applications
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“Similarly, aggressive risk factor management strategy has been shown to improve the long-term arrhythmia-free survival following catheter ablation for AF in conjunction with improved metabolic status in those with body mass index ≥27 kg/m(2) at study baseline.(22) Aggressive risk factor management comprised of 3-month…”
BackgroundSelf-citationAtrial fibrillation and stroke prevention: 25 years of research at EP Europace journal
Lip, G. Y. H., Proietti, M., Potpara, T., MANSOUR, M. C., Savelieva, I., Tse, H., Goette, A., Camm, A. J., Blomström‐Lundqvist, C., Gupta, D., et al. (2023) · EP Europace · doi:10.1093/europace/euad226 · Cited by 171 · see citing works
Alcohol and incident atrial fibrillation – A systematic review and meta-analysis
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Self-citationJCS/JHRS 2019 guideline on non‐pharmacotherapy of cardiac arrhythmias
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Electroanatomical Remodeling of the Atria in Obesity
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Self-citationCatheter Ablation of Atrial Fibrillation
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Risk Factor Management in Atrial Fibrillation
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Assessment of Left Atrial Fibrosis by Late Gadolinium Enhancement Magnetic Resonance Imaging
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“Therapeutic measures to reduce the risk for AF, such as blood pressure control, moderate exercise, and optimization of other comorbidities, have already been shown to be effective in certain groups of patients (theoretically by reducing the fibrotic burden) (35,42,43).”
BackgroundRhythm control in atrial fibrillation
Piccini, J. P., & Fauchier, L. (2016) · The Lancet · doi:10.1016/s0140-6736(16)31277-6 · Cited by 145 · see citing works
Goette, A., Kalman, J. M., Aguinaga, L., Akar, J. G., Cabrera, J. Á., Chen, S. A., Chugh, S. S., Corradi, D., d’Ávila, A., Dobrev, D., et al. (2016) · Journal of Arrhythmia · doi:10.1016/j.joa.2016.05.002 · Cited by 148 · see citing works
“Recent preliminary studies have suggested that aggressive treatment of hypertension improves post-ablation outcomes [200,464,465].”
Self-citationMehra, R., Chung, M. K., Olshansky, B., Dobrev, D., Jackson, C. L., Kundel, V., Linz, D., Redeker, N. S., Redline, S. S., Sanders, P., et al. (2022) · Circulation · doi:10.1161/cir.0000000000001082 · Cited by 156 · see citing works
Self-citationDiagnosis, pathophysiology, and management of exercise-induced arrhythmias
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Kirchhof, P. F., BREITHARDT, G. E., Bax, J. J., Benninger, G., Blomström‐Lundqvist, C., Boriani, G., Brandes, A., Brown, H., Brueckmann, M., Calkins, H. G., et al. (2015) · EP Europace · doi:10.1093/europace/euv304 · Cited by 141 · see citing works
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Impact of Obesity on Atrial Fibrillation Pathogenesis and Treatment Options
Sha, R., Baines, O., Hayes, A., Tompkins, K., Kalla, M., Holmes, A. P., O’Shea, C., & Pavlović, D. (2023) · Journal of the American Heart Association · doi:10.1161/jaha.123.032277 · Cited by 145 · see citing works
The importance of sleep-disordered breathing in cardiovascular disease
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- Authors
- Pathak, R. K., Middeldorp, M. E., Lau, D. H., Mehta, A. B., Mahajan, R., Twomey, D., Alasady, M., Hanley, L., Antic, N. A., McEvoy, R. D., Kalman, J. M., Abhayaratna, W. P., & Sanders, P.
- Affiliations
- Royal Adelaide Hospital (AU)
- Australian National University (AU)
- Flinders University (AU)
- The Royal Melbourne Hospital (AU)
- Corresponding author
- Sanders, Prashanthan
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2014-12
- Volume
- 64
- Issue
- 21
- Pages
- 2222-2231
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W140098974
- Semantic Scholar
- f4c9c27c3ab3730d2c2ca09e8648704e91ba7fde
- Cited by
- 949
- References
- 44
- Citations by year
- 2026: 57 · 2025: 85 · 2024: 72 · 2023: 73 · 2022: 81 · 2021: 107 · 2020: 97 · 2019: 80 · 2018: 70 · 2017: 92 · 2016: 79 · 2015: 52 · 2014: 4
- FWCI
- 52.00
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Flinders Academic Commons (Flinders University) (publishedVersion)
- ANU Open Research (Australian National University) (submittedVersion)
- Adelaide Research & Scholarship (AR&S) (University of Adelaide) (submittedVersion)
- Flinders Academic Commons (Flinders University) (submittedVersion)
- Funders
- ResMed
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Keywords
- atrial fibrillation, catheter ablation, cardiovascular risk management, obesity, weight loss, blood pressure reduction, glycemic control, lipid profile, arrhythmia-free survival, atrial fibrillation substrate, antiarrhythmic drugs, atrial fibrillation recurrence
- MeSH terms
- Alcohol Drinking, Atrial Fibrillation, Blood Glucose, Blood Pressure, Female, Follow-Up Studies, Glycated Hemoglobin, Humans, Life Style, Lipids, Male, Middle Aged, Recurrence, Risk Factors, Severity of Illness Index, Cohort Studies, Body Mass Index, Case-Control Studies, Smoking Cessation, Catheter Ablation, Sleep Apnea, Obstructive, Dyslipidemias, Weight Reduction Programs
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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