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Aggressive Risk Factor Reduction Study for Atrial Fibrillation and Implications for the Outcome of Ablation
Open accessAbstract
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%.330,704,706,710–715”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [330]
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“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]
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“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]
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“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]
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“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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“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
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“glycemic control, smoking and alcohol control, and sleepdisordered breathing control.(155) Overall, 69 of these patients”
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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 242
Associations of Epicardial, Abdominal, and Overall Adiposity With Atrial Fibrillation
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Self-citation2020 Clinical guidelines for Atrial fibrillation and atrial flutter
Arakelyan, M. S., Bockeria, L. A., Vasilieva, E., Sp, G., Golukhova, E. Z., Gorev, M. V., Davtyan, K. V., Drapkina, O. M., Станиславовна, К. Е., Kuchinskaya, Е. А., et al. (2021) · Russian Journal of Cardiology · doi:10.15829/1560-4071-2021-4594 · Cited by 258
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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 226
Self-citationFibrotic Atrial Cardiomyopathy, Atrial Fibrillation, and Thromboembolism
Hirsh, B. J., Copeland-Halperin, R. S., & Halperin, J. L. (2015) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2015.03.557 · Cited by 214
“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 217
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
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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
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
“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 176
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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
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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-citationDiagnosis, pathophysiology, and management of exercise-induced arrhythmias
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The importance of sleep-disordered breathing in cardiovascular disease
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Metadata
- 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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