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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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Self-citationThrombogenic Risk in Patients With Atrial Fibrillation
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Self-citationClinical, electrophysiological and imaging predictors of atrial fibrillation ablation outcome
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BackgroundCatheter Ablation of Persistent Atrial Fibrillation
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“This hypothesis is supported by results of recent study that showed that aggressive management of these conditions is associated with a better arrhythmia-free survival after catheter ablation.(15) AF termination in patients with persistent AF is not an easy task.”
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Management of patients with arterial hypertension and atrial fibrillation
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“The Australian ARREST-AF study displayed the benefits of aggressively managing hypertension, obesity, hyperlipidemia, and diabetes in reducing AF recurrence post ablation [34].”
BackgroundLoring, Z., Shrader, P. J., Allen, L. A., Blanco, R. G., Chan, P. S., Ezekowitz, M. D., Fonarow, G. C., Freeman, J. V., Gersh, B. J., Mahaffey, K. W., et al. (2019) · American Heart Journal · doi:10.1016/j.ahj.2019.10.008 · Cited by 13
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Self-citationObesity paradox in atrial fibrillation: a distracting reality or fictitious finding?
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Self-citationUpstream Targets to Treat Atrial Fibrillation
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Self-citationMechanistic Insights From Trials of Atrial Fibrillation Ablation: Charting a Course for the Future
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InfluentialAblation of atrial fibrillation
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“The intervention patients also had statistically lower symptom frequency and severity at follow-up.(18) The POWDER-AF trial importantly highlights that the long-term”
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Urinary isoxanthopterin as a novel predictor following catheter ablation for atrial fibrillation
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Depression and Physical Inactivity as Confounding the Effect of Obesity on Atrial Fibrillation
Garimella, R. S., Sears, S. F., & Gehi, A. K. (2016) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2016.03.012 · Cited by 12
Stabile, G., Trines, S. A. I. P., Arbelo, E., Dagres, N., Brugada, J., Kautzner, J., Pokushalov, E. A., Maggioni, A. P., Laroche, C., Anselmino, M., et al. (2019) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.13600 · Cited by 12
Pacholczak‐Madej, R., Bazan‐Socha, S., Zaręba, L., Undas, A., & Dropiński, J. (2020) · International Journal of Cardiology · doi:10.1016/j.ijcard.2020.09.037 · Cited by 13
Wang, W., Norby, F. L., Rooney, M. R., Zhang, M. J., Gutiérrez, A., Garg, P. K., Soliman, E. Z., Alonso, Á., Dudley, S. C., Lutsey, P. L., et al. (2020) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2020.09.033 · Cited by 12
Vrachatis, D. A., Papathanasiou, K. A., Kossyvakis, C., Giotaki, S. G., Raisakis, K., Iliodromitis, K. E., Reimers, B., Stefanini, G. G., CLEMAN, M. W., Sianos, G., et al. (2021) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2021.108724 · Cited by 11
Furui, K., Morishima, I., Morita, Y., Kanzaki, Y., Takagi, K., Nagai, H., Watanabe, N., Yoshioka, N., Yamauchi, R., Miyazawa, H., et al. (2021) · Circulation Journal · doi:10.1253/circj.cj-21-0218 · Cited by 12
Cancer, Inflammation, and Thrombosis: Drivers of Atrial Fibrillation in Oncology Patients
Awashra, A., Abdul‐Hafez, H. A., Swalha, M., Samara, E., Mahafdah, B., AbuBaha, M., Emara, A., Zahran, A., Elgendy, M. S., & Shubietah, A. R. M. (2025) · Clinical and Applied Thrombosis/Hemostasis · doi:10.1177/10760296251408388 · Cited by 12
“Structured weight-loss and risk-factor programs (ARREST-AF, LEGACY) reduced AF burden and improved rhythm outcomes, 80,81 while a randomized trial showed alcohol abstinence lowers AF recurrences.”
Scheurlen, C., van den Bruck, J., Filipovic, K., Wörmann, J., Arica, Z., Erlhöfer, S., Dittrich, S., Heijman, J., Lüker, J., Steven, D., et al. (2022) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-022-01210-3 · Cited by 11
Advances in Atrial Fibrillation Management: A Guide for General Internists
Pham, H. N., Ibrahim, R., Hieu, T. H., Sainbayar, E., Tran, V. N., Abdelnabi, M. H., Kanaan, C. N., & Sridharan, A. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13247846 · Cited by 13
Atrial fibrillation ablation timing: where is the sweet spot?
Kalman, J. M., Kistler, P. M., Hindricks, G., & Sanders, P. (2025) · European Heart Journal · doi:10.1093/eurheartj/ehae892 · Cited by 11
Self-citationVlachakis, P. K., Theofilis, P., Apostolos, A., Karakasis, P., Ktenopoulos, N., Boulmpou, A., Drakopoulou, M., Leontsinis, I., Xydis, P., Kordalis, A., et al. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm14092919 · Cited by 11
“%) reduces the recurrence risk by mitigating these substrate alterations, highlighting their reversibility [30,31].”
Surgical Weight Loss and Atrial Fibrillation
Kalman, J. M., Nalliah, C. J., & Sanders, P. (2016) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2016.09.941 · Cited by 12
Self-citationCalkins, 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) · Journal of Arrhythmia · doi:10.1016/j.joa.2017.07.001 · Cited by 11
Self-citationDalia, A. A., Kuo, A. S., Vanneman, M. W., Crowley, J., Elhassan, A. O., & Lai, Y. (2019) · Journal of Cardiothoracic and Vascular Anesthesia · doi:10.1053/j.jvca.2019.08.046 · Cited by 11
Lifestyle as a Risk Factor for Atrial Fibrillation
Gallagher, C., Middeldorp, M. E., Hendriks, J., Lau, D. H., & Sanders, P. (2021) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2020.11.013 · Cited by 12
Self-citationTutuianu, C. I., Szilagy, J., Pap, R., & Sághy, L. (2015) · PubMed Central · doi:10.4022/jafib.1226 · Cited by 11
Aerobic Interval Training Prevents Age-Dependent Vulnerability to Atrial Fibrillation in Rodents
Malmo, V., Kelly, A., Garten, K., Stølen, T., Rolim, N. P. L., Wisløff, U., Smith, G. L., & Loennechen, J. P. (2018) · Frontiers in Physiology · doi:10.3389/fphys.2018.00206 · Cited by 11
“Modification of risk factors for AF reduced AF burden and improved outcome after radiofrequency ablation (Pathak et al., 2014).”
BackgroundRisk Factor Management Before and After Atrial Fibrillation Ablation
Ariyaratnam, J., Middeldorp, M. E., Thomas, G., Noubiap, J. J., Lau, D. H., & Sanders, P. (2020) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2020.02.009 · Cited by 12
Self-citationThe Liraglutide Effects in Atrial Fibrillation (LEAF) Study
Goldberger, J. J., Mitrani, R. D., Fishman, J. E., Zaatari, G., Lowery, M. H., Baez-Garcia, C., Aguilar, V., Blandon, C., Hurwitz, B. E., Velasquez, A. H., et al. (2026) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2026.03.026 · Cited by 10
Impact of Weight Loss on Atrial Fibrillation
Ahammed, M. R., & Ananya, F. N. (2023) · Cureus · doi:10.7759/cureus.46232 · Cited by 13
The impact of lifestyle factors on atrial fibrillation
Lim, M. W., & Kalman, J. M. (2024) · Journal of Molecular and Cellular Cardiology · doi:10.1016/j.yjmcc.2024.05.015 · Cited by 10
Self-citationNoubiap, J. J., Pathak, R. K., Thomas, G., Elliott, A. D., Sanders, P., & Middeldorp, M. E. (2024) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.123.012534 · Cited by 10
Self-citationAtrial Cardiomyopathy: From Diagnosis to Treatment
Liu, Z., Liu, T., & Wu, G. (2025) · Reviews in Cardiovascular Medicine · doi:10.31083/rcm25124 · Cited by 12
Clinical Assessment of People With Obesity: Focus on Adiposity-Related Multimorbidity
Bianchettin, R. G., Gawey, B. J., Acosta, A. J., Borlaug, B. A., Caples, S. M., Collazo–Clavell, M. L., Clark, M. M., Lara-Breitinger, K. M., Lerman, A., Lerman, L. O., et al. (2025) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2025.02.021 · Cited by 13
Blood pressure in patients with atrial fibrillation: part 2—treatment
Cohen, D. L., & Townsend, R. R. (2016) · Journal of Clinical Hypertension · doi:10.1111/jch.12939 · Cited by 10
Preventive Cardio-Oncology: Cardiovascular Disease Prevention in Cancer Patients and Survivors
Fabiani, I., Branch, M. E., Cardinale, D. M., Middeldorp, M. E., Sanders, P., Cohen, J. B., Cainzos‐Achirica, M., Jaiswal, S., & Brown, S.-A. N. (2021) · Current Treatment Options in Cardiovascular Medicine · doi:10.1007/s11936-020-00883-1 · Cited by 11
Self-citationBittman, J., Thomson, C. J., Lyall, L. A., Alexis, S. L., Lyall, E., Cannatella, S. L., Ebtia, M., Fritz, A., Freedman, B. K., Alizadeh-Pasdar, N., et al. (2022) · CJC Open · doi:10.1016/j.cjco.2022.04.004 · Cited by 13
“The nonrandomized Aggressive Risk Factor Reduction Study for Atrial Fibrillation and Implications for the Outcome of Ablation (Arrest AF), which employed aggressive risk-factor modification, with exercise and weight loss components, resulted in improved arrhythmia-free survival after AF ablation.(5) Similarly, a retro…”
ResultNgo, L., Woodman, R. J., Denman, R. A., Walters, T. E., Yang, I. A., & Ranasinghe, I. (2022) · European Heart Journal - Quality of Care and Clinical Outcomes · doi:10.1093/ehjqcco/qcac024 · Cited by 10
Han, W., Liu, Y., Sha, R., Liu, H., Liu, A., Maduray, K., Ge, J., Ma, C., & Zhong, J. (2022) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2022.934664 · Cited by 11
Ferreira‐Martins, J., Howard, J. P., Al-Khayatt, B. M., Shalhoub, J., Sohaib, A., Shun-Shin, M. J., NOVAK, P. G., Leather, R., Sterns, L. D., Lane, C. J., et al. (2018) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.13745 · Cited by 10
Nguyen, B., Rienstra, M., Hobbelt, A. H., Tijssen, J. G. P., Smit, M. D., Tieleman, R. G., Geelhoed, B., van Veldhuisen, D. J., Crijns, H. J. G. M., & Gelder, I. C. V. (2020) · American Heart Journal · doi:10.1016/j.ahj.2019.12.005 · Cited by 10
Mujović, N. M., Marinković, M. M., Nedeljković, I., Marković, N., Banovic, M. D., Vučićević, V., Stankovic, G. R., & Potpara, T. (2021) · Journal of the American Heart Association · doi:10.1161/jaha.120.017445 · Cited by 10
Dalmar, A., Singh, M., Heis, Z., Cumpian, T. L., Ceretto, C., Mortada, M. E., Bhatia, A., Niazi, I. K., Chua, T. Y., Sra, J. S., et al. (2021) · Stroke · doi:10.1161/strokeaha.120.031920 · Cited by 10
Lee, D. P. H., Hoffmayer, K. S., Hsu, J. C., Schricker, A. A., Birgersdotter-Green, U. M., Raissi, F., Feld, G. K., & Krummen, D. E. (2019) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-019-00520-3 · Cited by 10
Life’s Simple 7 Approach to Atrial Fibrillation Prevention
Sperling, L. S. (2018) · Journal of Atrial Fibrillation · doi:10.4022/jafib.2051 · Cited by 11
Mehra, N. S., Kowlgi, G. N., & Deshmukh, A. J. (2020) · Current Cardiovascular Risk Reports · doi:10.1007/s12170-020-00645-5 · Cited by 10
Catheter Ablation for Atrial Fibrillation
Albert, C. M., & Bhatt, D. L. (2019) · JAMA · doi:10.1001/jama.2018.17478 · Cited by 10
Lurz, J. A., Hengelhaupt, L., Unterhuber, M., Stenzel, L., Hilbert, S., Schöber, A. R., Dinov, B., Darma, A., Dagres, N., Hindricks, G., et al. (2024) · Journal of the American Heart Association · doi:10.1161/jaha.123.033500 · Cited by 9
van Deutekom, C., Hendriks, J., Myrstad, M., Gelder, I. C. V., & Rienstra, M. (2024) · Expert Review of Cardiovascular Therapy · doi:10.1080/14779072.2024.2416666 · Cited by 11
“The observational ARREST-AF cohort study found that risk factor management improved arrhythmia-free survival after AF ablation [88].”
Szilágyi, J., & Sághy, L. (2020) · Current Cardiology Reviews · doi:10.2174/1573403x16666200721153620 · Cited by 9
“Risk factor management (RFM) [129]* HR 4.”
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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