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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]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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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Self-citationPersistent Atrial Fibrillation From the Onset
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BackgroundInfluentialExercise Training and Atrial Fibrillation
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BackgroundInfluentialPatient-Centered Educational Resources for Atrial Fibrillation
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“Risk factor treatment including hypertension, obesity, obstructive sleep apnoea, diabetes mellitus, and alcohol excess form an important pillar in AF management.(17,18) The ARREST AF study demonstrated that aggressive risk factor management”
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“Combining several targets increases success rates: aggressive risk factor reduction after AF ablation not only increased arrhythmia-free survival compared to standard care, but also significantly reduces left atrial volumes, suggesting a reversing effect on atrial myopathy [43, 211].”
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“Biobehavioral outcomes of programs designed to improve physical fitness and the cardiovascular risk factor profile of patients diagnosed with AF have been reported, 8,15 but how patients describe their experience in participating in these programs is lacking.”
Exercise-based cardiac rehabilitation for adults with atrial fibrillation
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“Interventions that have demonstrated marked improvements in cardiovascular risk factor status in AF have simultaneously addressed multiple factors in a single intervention within a dedicated clinic.(18,34) The impact of a clinic combining holistic AF care and risk factor management in a single intervention has not bee…”
BackgroundMethodInfluentialSelf-citationIncidence and Predictors of Heart Failure in Patients With Atrial Fibrillation
Krisai, P., Johnson, L., Moschovitis, G., Benz, A. P., Ramasundarahettige, C. F., McIntyre, W. F., Wong, J. A., Conen, D., Sticherling, C., Connolly, S. J., et al. (2021) · CJC Open · doi:10.1016/j.cjco.2021.07.016 · Cited by 22
“and positive remodelling of left atrial and left ventricular size.(21,22) The next key component is optimal medical management, including drugs that have shown benefits in HF populations.”
BackgroundHarmful Impact of Tobacco Smoking and Alcohol Consumption on the Atrial Myocardium
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“management consisting of BP control, weight management, lipid management, glycemic control, SDB management, and smoking and alcohol counseling.(137) Compared to the control group, patients”
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Self-citationObstructive Sleep Apnea Treatment and Atrial Fibrillation: A Need for Definitive Evidence
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“001 Previous thromboembolism, n (%) 214/3060 (7) 200/2843 (7) 14/217 (6.”
Long‐Term Impact of GLP‐1 Receptor Agonists on AF Recurrence After Ablation in Obese Patients
Patel, H., Sheth, A. R., Nair, A. V., Patel, B. A., Thakkar, S. J., Narasimhan, B., Mehta, N. K., Asad, Z. U. A., Kowlgi, G. N., DeSimone, C. V., et al. (2025) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.16737 · Cited by 21
“Weight loss has been shown to reduce AF risk and recurrence in this patient population, with prior research demonstrating that weight loss of 10% or more is associated with improved arrhythmia ‐ free survival [8].”
Lane, D. A., Andrade, J. G., Arbelo, E., Boriani, G., Hendriks, J., Lee, S., Lip, G. Y. H., Mant, J., & Middeldorp, M. E. (2026) · The Lancet · doi:10.1016/s0140-6736(25)02166-x · Cited by 25
Self-citationProlonged atrial refractoriness predicts the onset of atrial fibrillation: A 12-year follow-up study
Lee, J., Lee, H., Janardhan, A. H., Park, J., Joung, B., Pak, H., Lee, M., Kim, S. S., & Hwang, H. J. (2016) · Heart Rhythm · doi:10.1016/j.hrthm.2016.03.037 · Cited by 21
“One question that arises is whether prolonged AERP returns to baseline once aggressive AF risk factor modification is undertaken, and is an area of future study.(33,34) In our study, hypertension, DM, and high BMI, wellknown risk factors of AF, were not significantly associated with the new-onset AF by Cox proportiona…”
BackgroundAssociation between socioeconomic status and incident atrial fibrillation
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Metabolic Syndrome and Atrial Fibrillation: Different Entities or Combined Disorders
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Risk Factor Management and Atrial Fibrillation Clinics: Saving the Best for Last?
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“additional risk factor were allocated to either a structured weight loss program and aggressive risk factor management or routine care [23].”
Self-citationYaeger, A., Cash, N. R., Parham, T., Frankel, D. S., Deo, R., Schaller, R. D., Santangeli, P., Nazarian, S., Supple, G. E., Arkles, J., et al. (2018) · Journal of the American Heart Association · doi:10.1161/jaha.118.010414 · Cited by 21
“Pathak et al have shown, in a series of observational studies, that a comprehensive physician-directed RFM model can improve long-term maintenance of sinus rhythm in AF patients regardless of the management strategy.(3,4) Although quite successful, this RFM approach was fairly labor intensive.”
BackgroundResultInfluentialThe Impact of Alcohol Intake on Atrial Fibrillation
Voskoboinik, A., & Marcus, G. M. (2020) · Current Cardiology Reports · doi:10.1007/s11886-020-01369-z · Cited by 21
Innovations and paradigm shifts in atrial fibrillation ablation
Mulder, B. A., LUERMANS, J. G. L. M., Hindricks, G., & Blaauw, Y. (2020) · EP Europace · doi:10.1093/europace/euaa418 · Cited by 20
Atrial Fibrillation in Endurance Athletes
Elliott, A. D., Mahajan, R., Lau, D. H., & Sanders, P. (2016) · Cardiology Clinics · doi:10.1016/j.ccl.2016.06.006 · Cited by 30
Self-citationNovel advances in cardiac rehabilitation
Vromen, T., Brouwers, R. W. M., Jorstad, H. T., Kraaijenhagen, R. A., Spee, R. F., Wittekoek, M. E., Cramer, M. J., van Hal, J. M. C., Hofstra, L., Kuijpers, P. M. J. C., et al. (2021) · Netherlands Heart Journal · doi:10.1007/s12471-021-01585-4 · Cited by 21
Vermeer, J. R., Greef, T. V.-D., van den Broek, J. L. P. M., de Louw, B., van Steenbergen, G. J., van Veghel, D., & Dekker, L. (2025) · European Heart Journal · doi:10.1093/eurheartj/ehaf689 · Cited by 20
Vermeer, J. R., Greef, T. V.-D., de Louw, B., Slingerland, S. R., Veer, M. V. ’., Regis, M., Jansen, J.-M., van den Heuvel, E. R., & Dekker, L. (2023) · Clinical Research in Cardiology · doi:10.1007/s00392-023-02185-5 · Cited by 19
“The observational ARREST-AF and LEGACY trials clearly demonstrate beneficial effects on ablation outcomes when the management of different risk factors is combined [11, 22].”
BackgroundThanigaimani, S., Mclennan, E., Linz, D., Mahajan, R., Agbaedeng, T. A., Lee, G., Kalman, J. M., Sanders, P., & Lau, D. H. (2017) · Progress in Biophysics and Molecular Biology · doi:10.1016/j.pbiomolbio.2017.07.010 · Cited by 22
Self-citationYaeger, A., Keenan, B. T., Cash, N. R., Parham, T., Deo, R., Frankel, D. S., Schaller, R. D., Santangeli, P., Nazarian, S., Supple, G. E., et al. (2020) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.14336 · Cited by 20
“These studies entailed aggressive and comprehensive management of multiple risk factors.(3,4) Although effective, this approach to RFM is resource‐intensive.”
BackgroundPersistent Atrial Fibrillation Ablation: Where Do We Go From Here?
Verma, A., & Macle, L. (2018) · Canadian Journal of Cardiology · doi:10.1016/j.cjca.2018.08.008 · Cited by 20
Litvin, A. Y., Chazova, I. E., Elfimova, E. M., Pevzner, A. V., Poluektov, M. G., Danilov, N. M., Mikhailova, O. O., & Владимировна, А. А. (2024) · Eurasian heart journal · doi:10.38109/2225-1685-2024-3-6-27 · Cited by 21
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Proietti, R., Birnie, D. H., Ziegler, P., Wells, G. A., & Verma, A. (2018) · Journal of the American Heart Association · doi:10.1161/jaha.118.010256 · Cited by 19
Donnellan, E., Wazni, O. M., Harb, S. C., Kanj, M. H., Saliba, W. I., & Jaber, W. A. (2020) · Heart Rhythm · doi:10.1016/j.hrthm.2020.05.013 · Cited by 19
Sleep apnea and atrial fibrillation: challenges in clinical and translational research
Linz, B. M., Hertel, J. N., Hendriks, J., Saljic, A., Dobrev, D., Baumert, M., Jespersen, T., & Linz, D. (2022) · Expert Review of Cardiovascular Therapy · doi:10.1080/14779072.2022.2036606 · Cited by 20
Earlier Prediction of Cardiovascular Risk with Epicardial Fat Assessment
Calcaterra, G., Varghese, R. T., Baroni, M., Capucci, A., Angeli, F., Iacobellis, G., & Verdecchia, P. (2025) · European Journal of Internal Medicine · doi:10.1016/j.ejim.2025.106481 · Cited by 19
Weinmann, K., Bothner, C., Rattka, M., Aktolga, D., Teumer, Y., Rottbauer, W., Dahme, T., & Pott, A. (2020) · International Journal of Cardiology · doi:10.1016/j.ijcard.2020.06.001 · Cited by 18
Atrial fibrillation and chronic heart failure: interrelationship and approaches to treatment
Gagloeva, D. A., Mironov, N. Y., Laiovich, L. I., Миронова, Н. А., & Sp, G. (2021) · Russian Cardiology Bulletin · doi:10.17116/cardiobulletin2021160215 · Cited by 19
Wang, T., Cheng, J., & Wang, Y. (2022) · Genes & Nutrition · doi:10.1186/s12263-022-00708-9 · Cited by 19
Bisson, A., Fawzy, A. M., El‐Bouri, W. K., Angoulvant, D., Lip, G. Y. H., Fauchier, L., & Clémenty, N. (2023) · Current Problems in Cardiology · doi:10.1016/j.cpcardiol.2023.101732 · Cited by 19
Akhtar, K. H., Jafry, A. H., Beard, C., NASIR, Y. M., Agarwal, S., Khan, J., Clifton, S. C., Reece, J., Munir, M. B., Deshmukh, A. J., et al. (2023) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.16090 · Cited by 18
“19 These results highlight the important role of weight loss among obese patients undergoing CA for AF.”
BackgroundSelf-citationRosselló, X., Ramallal, R., Romaguera, D., Alonso‐Gómez, Á. M., Alonso, Á., Tojal‐Sierra, L., Fernández-Palomeque, C., Martínez‐González, M. Á., Uriarte, M. G., López, L., et al. (2023) · European Journal of Preventive Cardiology · doi:10.1093/eurjpc/zwad380 · Cited by 18
“30 The use of echocardiography in this setting deserves special attention.”
Background‘What else can I do?’: Insights from atrial fibrillation patient communication online
Redman, K. N., Thorne, S. E., Lauck, S., & Taverner, T. (2016) · European Journal of Cardiovascular Nursing · doi:10.1177/1474515116678103 · Cited by 18
Shulman, E. H., Chudow, J., Essien, U. R., Shanbhag, A., Kargoli, F., Romero, J. E., Biase, L. D., Fisher, J. D., KRUMERMAN, A. K., & Ferrick, K. J. (2018) · International Journal of Cardiology · doi:10.1016/j.ijcard.2018.10.028 · Cited by 18
Atrial fibrillation and cardiac rehabilitation: an overview
Robaye, B., Lakiss, N., Dumont, F., & Laruelle, C. (2019) · Acta cardiologica. Supplementum · doi:10.1080/00015385.2019.1565663 · Cited by 19
“, aimed to examine this recurrence [14].”
Muzzey, M., Tellor, K. B., Ramaswamy, K., Schwarze, M. W., & Armbruster, A. L. (2020) · Therapeutic Advances in Cardiovascular Disease · doi:10.1177/1753944720926824 · Cited by 18
Predictors of recurrent atrial fibrillation following catheter ablation
Mohanty, S., Rocca, D. G. D., Gianni, C., Trivedi, C. G., Mayedo, A., MacDonald, B. C., & Natale, A. (2021) · Expert Review of Cardiovascular Therapy · doi:10.1080/14779072.2021.1892490 · Cited by 18
“[53] Consecutive series Risk-factor-management (hazard ratio 4.”
BackgroundObesity and Atrial Fibrillation: A Narrative Review
Gupta, V., Munjal, J., Jhajj, P., Jhajj, S., & Jain, R. (2022) · Cureus · doi:10.7759/cureus.31205 · Cited by 19
“Studies have shown the positive effect of weight loss and risk factor management on atrial fibrillation progression and recurrence [40].”
BackgroundHypertension, Prehypertension, Hypertensive Heart Disease, and Atrial Fibrillation
Lau, D. H., Shenasa, H. A., & Shenasa, M. (2021) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2020.11.009 · Cited by 18
Self-citationEffects of Bariatric Surgery on Heart Rhythm Disorders: a Systematic Review and Meta-Analysis
Sanches, E. E., Topal, B., de Jongh, F. W., Çağıltay, E., Çelik, A., Sundbom, M., Ribeiro, R. J. D. S., Parmar, C. D., Ugale, S. M., Mahawar, K. K., et al. (2021) · Obesity Surgery · doi:10.1007/s11695-021-05314-z · Cited by 17
Fat: an emerging player in the field of atrial fibrillation
Auer, J. (2016) · European Heart Journal · doi:10.1093/eurheartj/ehw013 · Cited by 17
Mills, M. T., Futyma, P., Calvert, P. A. R., Penela, D., Roten, L., Perrotta, L., Migliore, F., Lip, G. Y. H., Gupta, D., & Chun, K. R. J. (2025) · EP Europace · doi:10.1093/europace/euaf075 · Cited by 16
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“40,41 SGLT2i use has demonstrated robust benefits in reducing the risk of adverse events across these comorbidities.”
Boehmer, A. A., Rothe, M., Nussbaum, E., Ruckes, C., Dobre, B. C., Kaess, B. M., & Ehrlich, J. R. (2023) · IJC Heart & Vasculature · doi:10.1016/j.ijcha.2023.101244 · Cited by 16
Vermeer, J. R., van den Broek, J. L. P. M., & Dekker, L. (2024) · International Journal of Cardiology Cardiovascular Risk and Prevention · doi:10.1016/j.ijcrp.2024.200344 · Cited by 17
The Close Link Between Obesity and Cardiovascular Disease
Lee, H., Rhee, T., Choi, J. M., Choi, S., & Kim, D. W. (2025) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/j.ecl.2024.10.005 · Cited by 19
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Relationship Between Obstructive Sleep Apnoea and AF
Shantha, G. P. S., Pelosi, F., & Morady, F. (2019) · Arrhythmia & Electrophysiology Review · doi:10.15420/aer.2019.35.2 · Cited by 17
“Weight loss consistently reduces OSA severity and improves AF burden, AF symptom scores and potentially reverses cardiac remodelling.(56,57)”
BackgroundObesity and Metabolic Syndrome in Atrial Fibrillation
Mahajan, R., & Wong, C. X. J. (2021) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2020.11.006 · Cited by 16
Self-citationSymptoms and health‐related quality of life 5 years after catheter ablation of atrial fibrillation
Walfridsson, U., Jönsson, A. H., Karlsson, L., Liuba, I., Almroth, H., Sandgren, E., Walfridsson, H., & Charitakis, E. (2021) · Clinical Cardiology · doi:10.1002/clc.23752 · Cited by 16
“There is solid evidence regarding the positive effects of lifestyle management, which can lead to a reduced symptom burden, absence of AF, and positive effects on comorbidities.(26,28) The third predictive factor seen was IHD, giving a threefold increased risk of having arrhythmia‐related symptoms five years after the…”
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“The risk of AF has been related to classical cardiovascular risk factors, although age is the most critical risk factor for AF [2,3].”
Background
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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