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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.
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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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“In ARREST-AF [35], 281 patients who had undergone AF ablation with BMI ≥ 27 and ≥ 1 risk factor were offered LRFM management, consisting of a structured program using face-to-face counseling, a diet plan, diet and physical activity diaries, and visits every 3 months.”
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“Similarly, the ARREST-AF study showed that weight reduction with other risk factor modifications resulted in longer arrhythmia-free survival after AF ablation (Pathak et al., 2014).”
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“In another study, the same researchers evaluated the effects of risk factor severity reduction, including weight reduction, blood pressure control, lipid management, glycemic control, therapy for OSA, and alcohol and smoking cessation, on outcomes of AF ablation (6).”
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“16 Therefore, it was not clear whether the recurrence of AF/AT was due to poor disease awareness, poor serial changes in modifiable risk factors, or the original patient background as multiple cofounders.”
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“The contemporary treatment of AF is complex and not only consists of oral anticoagulation, rate and rhythm control but also risk factor management, emphasizing the need for innovative approaches such as integrated care model [5 – 7].”
BackgroundSelf-citationZakynthinos, G. Ε., Tsolaki, V., Oikonomou, E. K., Pantelidis, P., Gialamas, I., Kalogeras, K. I., Zakynthinos, E. G., Vavuranakis, Μ., & Siasos, G. (2024) · International Journal of Molecular Sciences · doi:10.3390/ijms25042317 · Cited by 4
“…to enhanced ablation success rates In the context of the ARREST-AF Cohort Study, the study highlights the importance of aggressively managing multiple risk factors, leading to enhanced ablation success rates and increased arrhythmia-free survival [107]. increased arrhythmia-free survival [107].”
BackgroundScreening for Atrial Fibrillation: Risks, Benefits, and Implications On Future Clinical Practice
Ilyas, M. H., Sharih, A. M., Jido, J. T., Ali, A. R. Z., Khoshnaghsh, A., Nadeem, M., & Zahra, S. A. (2024) · Current Treatment Options in Cardiovascular Medicine · doi:10.1007/s11936-024-01047-1 · Cited by 3
“Participants who engaged with RFM demonstrated improved outcomes of ablation including AF frequency, duration, and symptoms [26].”
Representation of obesity in contemporary atrial fibrillation ablation randomized controlled trials
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“14,15,17,41,42 Many trials demonstrated that lifestyle modification could offer a non-inferior counterpart to catheter ablation.”
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“The ARREST-AF study evaluated the effects of aggressive risk factor management (RFM) in 149 overweight and obese patients (BMI ≥ 27 kg/m 2 ) who underwent catheter ablation [58].”
Nurse-led atrial fibrillation clinics in primary health care: a review of the evidence
Dahlberg, M., & Jakobsson, U. (2025) · Scandinavian Journal of Primary Health Care · doi:10.1080/02813432.2025.2466175 · Cited by 5
“…these patients to manage numerous comorbidities, and focus on lifestyle modifications [3] such as weight management, blood pressure control, smoking and alcohol cessation. these modifications are examples of factors that show a positive impact on the progression of aF and could even prevent aF [8].”
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BackgroundRisk Factor Management in Atrial Fibrillation: How to Deliver a Successful Clinic
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Relation of Functional Status to Risk of Development of Atrial Fibrillation
Ramkumar, S., Yang, H., Wang, Y., Nolan, M. T., Negishi, K., Sanders, P., & Marwick, T. H. (2016) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2016.10.043 · Cited by 3
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.2017.05.001 · Cited by 2
Self-citationSrivatsa, U. N., Danielsen, B. H., Amsterdam, E. A., Yang, Y., Fan, D., Pezeshkian, N. G., & White, R. H. R. (2017) · Journal of Atrial Fibrillation · doi:10.4022/jafib.1599 · Cited by 3
Does Lifestyle Impact Risk, Burden, and Symptomatology of Atrial Fibrillation?
Parkash, R. (2018) · Canadian Journal of General Internal Medicine · doi:10.22374/cjgim.v13isp1.310 · Cited by 3
Trenkwalder, T., Grebmer, C., Tydecks, M., Blažek, P., Kottmaier, M., Weigand, S., Bourier, F. J., Reents, T., Reinhard, W., Lennerz, C., et al. (2021) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2021.03.029 · Cited by 3
Fitness and the Development of Atrial Fibrillation
Bhatt, A. G., & Monahan, K. M. (2015) · Circulation · doi:10.1161/circulationaha.115.016596 · Cited by 3
“Abed et al15 demonstrated that in sheep excessive caloric intake leading to weight gain was associated with adverse atrial remodeling marked by increased left atrial mass, fibrosis, inflammation, slower and more heterogeneous atrial conduction, and greater burden of AF.”
MethodInfluentialPathak, R. K., Mahajan, R., Lau, D. H., & Sanders, P. (2015) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2015.08.885 · Cited by 3
Self-citationHyman, M. C., & Callans, D. J. (2016) · Circulation · doi:10.1161/circulationaha.116.024636 · Cited by 3
Reducing Risk of Dementia in AF—Is Oral Anticoagulation the Key?
Gallagher, C., Lau, D. H., & Sanders, P. (2018) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2017.12.017 · Cited by 3
Self-citationBlack‐Maier, E., & Daubert, J. P. (2018) · Trends in Cardiovascular Medicine · doi:10.1016/j.tcm.2018.07.006 · Cited by 3
Dixit, S. (2022) · Trends in Cardiovascular Medicine · doi:10.1016/j.tcm.2022.11.002 · Cited by 3
Win, K. Z., Armstrong, M. J., Steeds, R. P., & Kalla, M. (2024) · Pilot and Feasibility Studies · doi:10.1186/s40814-024-01454-y · Cited by 4
Actualización en rehabilitación cardiaca en el paciente crítico cardiovascular: una revisión de tema
Serna–Trejos, J. S., Castro–Galvis, C. A., Bermúdez–Moyano, S. G., Rodríguez–Fonseca, L. C., Montenegro, A. A., Miño–Bernal, J. F., Rodríguez, L. M. S., & Bravo-Echeverry, V. (2025) · Acta Colombiana de Cuidado Intensivo · doi:10.1016/j.acci.2025.01.004 · Cited by 2
Catheter ablation of atrial fibrillation in the practice of a cardiologist and therapist: A review
Serova, M. V., Sazonova, Y. S., Сафонов, Н. В., Bilaya, O. P., & Andreev, D. A. (2025) · Consilium Medicum · doi:10.26442/20751753.2025.1.203052 · Cited by 2
Vermeer, J. R., van den Broek, J. L. P. M., Greef, T. V.-D., Janssen, H. C. J. P., van Hirtum, P. V., Overeem, S., & Dekker, L. (2025) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-025-02131-7 · Cited by 2
Valls, A. C., Martínez-Momblán, M.-A., Carro, E., Niebla, M., Domingo, R., Hevia-Puyo, S., Nieto, M. V., Borràs, R., Tolosana, J. M., Porta‐Sánchez, A., et al. (2026) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.125.014149 · Cited by 2
Hasanein, D., Lighezan, D.-F., Țunea, O. E., Ciobotaru, V. G., & Basa, N. S. (2026) · Journal of Clinical Medicine · doi:10.3390/jcm15051899 · Cited by 2
“The ARREST-AF and LEGACY studies provided proof-of-concept that aggressive risk factor management—including weight loss, blood pressure control, glycemic control, OSA treatment, alcohol reduction, and smoking cessation—can reduce AF burden by up to 50% and improve arrhythmia-free survival [40,41].”
Richard-Vitton, R., Nguyen, K., Franceschi, F., Fauchier, L., Hourdain, J., Koutbi, L., Tovmassian, L., Wilkin, M., Biermé, C., Schemoul, E., et al. (2026) · European Heart Journal · doi:10.1093/eurheartj/ehag205 · Cited by 2
Evaluating the benefits of home-based management of atrial fibrillation: current perspectives
Sheikh, A. B., Felzer, J., Munir, A., Morin, D. P., & Lavie, C. J. (2016) · Pragmatic and Observational Research · doi:10.2147/por.s96670 · Cited by 2
“001).(87) Weight loss is always encouraged to attenuate risk factors for AF such as HTN, T2DM, and OSA.”
Healthy lifestyle and prevention of atrial fibrillation: Weighty matters
Aeschbacher, S., & Conen, D. (2018) · European Journal of Preventive Cardiology · doi:10.1177/2047487318791005 · Cited by 3
Atrial Fibrillation and Epicardial Adipose Tissue
Zaatari, G., & Goldberger, J. J. (2020) · Contemporary cardiology · doi:10.1007/978-3-030-40570-0_10 · Cited by 3
Schmidt, M. M., Griffin, J. M., McCabe, P. J., Stuart-Mullen, L. G., Branda, M. E., O'Byrne, T. J., Bowers, M., Trotter, K., & McLeod, C. J. (2021) · PLoS ONE · doi:10.1371/journal.pone.0246861 · Cited by 2
“In light of recent evidence that highlights behavior modification as a predictor of post-ablation success [8, 9], our finding is especially encouraging.”
BackgroundMethodInfluentialGuichard, J.-B., Anselme, F., Defaye, P., Mansourati, J., Pavin, D., Pasquié, J., Saludas, Y., Barthélemy, J., Roche, F., Laporte, S., et al. (2021) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2021.09.010 · Cited by 2
Risom, S. S., Thygesen, L. C., Rasmussen, T. B., Borregaard, B., Nørgaard, M. W., Mols, R., Christensen, A. V., Thorup, C. B., Thrysoee, L., Juel, K., et al. (2022) · The Journal of Cardiovascular Nursing · doi:10.1097/jcn.0000000000000900 · Cited by 2
“89 1 582 (63) 241 (62) 2 238 (26) 98 (25) ≥3 71 (8) 34 (9) Outcomes up to 1 y after discharge, n (%) Acute contacts with hospital, AF diagnosis 333 (36) 112 (29) .”
Liu, H., Brobbey, A., Ejaredar, M., Lorenzetti, D., Sajobi, T. T., Arena, R. A., James, M. T., & Wilton, S. B. (2022) · Current Problems in Cardiology · doi:10.1016/j.cpcardiol.2022.101572 · Cited by 4
Xu, H., Chen, X., Zhang, Y., Zhu, K., Zhao, J., Qin, F., & Hailong, T. (2023) · Computational and Mathematical Methods in Medicine · doi:10.1155/2023/7892185 · Cited by 2
“Results of the ARREST-AF study proved that better management of risk factors like hypertension, diabetes, and obesity was linked with a lower AF recurrence rate after catheter ablation by decreasing LA remodeling [35].”
MethodWilliamson, T. M., Rouleau, C. R., Wilton, S. B., Valdarchi, A. B., Moran, C., Patel, S. N., Lutes, L. D., Aggarwal, S., Arena, R. A., & Campbell, T. S. (2024) · Trials · doi:10.1186/s13063-024-08527-6 · Cited by 2
“Weight loss corresponds to improvements in symptom burden among patients with established AF and comorbid obesity in a dose–response fashion [3, 6, 16, 17].”
BackgroundPapathanasiou, K. A., Vrachatis, D. A., Kossyvakis, C., Giotaki, S. G., Deftereos, G., Kousta, M. S., Anagnostopoulos, I., Avramidis, D., Γιαννόπουλος, Γ., Lambadiari, V., et al. (2024) · Clinics and Practice · doi:10.3390/clinpract14060192 · Cited by 2
“Randomized studies have previously suggested that weight reduction is beneficial for AF-related outcomes, such as arrhythmia free survival post-ablation [10], sinus rhythm maintenance [11], and AF regression [12].”
Hoshiyama, T., Ashikaga, K., Morihisa, K., Ito, M., Oniki, K., Saruwatari, J., Ishii, M., Kanazawa, H., Sumi, H., Kaneko, S., et al. (2024) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.124.013433 · Cited by 2
Vrachatis, D. A., Papathanasiou, K. A., Kazantzis, D., Anagnostopoulos, I., Kousta, M. S., Giotaki, S. G., Deftereos, G., Lambadiari, V., Γιαννόπουλος, Γ., Basdra, E. K., et al. (2025) · Biomedicines · doi:10.3390/biomedicines13020298 · Cited by 2
“From a clinical perspective, weight control should be strongly encouraged in obese patients, especially in view of its positive impact on arrhythmia-free survival post-ablation [32].”
An, J., Bansal, N., Zheng, C., Lee, M. S., Wei, R., Harrison, T. N., Fan, D., Garcia, E. A., Lidgard, B., Zelnick, L. R., et al. (2025) · Heart Rhythm O2 · doi:10.1016/j.hroo.2025.02.007 · Cited by 2
“18,19 However, this has not been studied extensively in real-world clinical settings.”
You, H., Li, S., Guo, X., Jiang, C., Zhou, L., He, L., Wang, W., Li, S., Tang, R., Liu, N., et al. (2025) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.15181 · Cited by 2
Tijskens, M., Abugattás-Torres, J. P., Wolf, M., Schwagten, B., & Greef, Y. D. (2025) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.16651 · Cited by 2
“Finally, it has to be stressed that the importance of lifestyle factors in AF pathophysiology has emerged in recent years [40, 41].”
Patient Centered mobile Health TECHnology Enabled Atrial Fibrillation Management (mTECH Afib)
Isakadze, N., Horstman, N. A., Ding, J., Eddy, C., Blair, S., Kim, C. H., Pham, L. V., Marvel, F. A., Spaulding, E. M., Nimbalkar, M., et al. (2025) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2025.02.015 · Cited by 3
Greca, C. L., Dell’Aquila, A., Prezioso, A., Bertini, M., Bianchi, V., Vitulano, G., Calò, L., Savarese, G., Santobuono, V. E., Russo, A. D., et al. (2025) · IJC Heart & Vasculature · doi:10.1016/j.ijcha.2025.101731 · Cited by 2
“However, although there have been variable results when targeting risk factors in isolation, comprehensive management has been shown to be effective in conferring tangible clinical improvements [8,9].”
Manresa‐Rocamora, A., Fuertes-Kenneally, L., Sempere-Ruiz, N., Blasco‐Peris, C., Ibáñez-Críado, A., Climent, V. E., & Sarabia, J. M. (2025) · Sports Medicine - Open · doi:10.1186/s40798-025-00906-w · Cited by 2
“The ARREST-AF trial demonstrated that exercise, accompanied by weight loss and risk factor management before catheter ablation, improved long-term maintenance of sinus rhythm over a 3-to 4-year period in patients with AF [70].”
Önder, R., Desteghe, L., Vijgen, J. M., Collins, R., Dąbrowski, R., Farkowski, M. M., Figueiredo, M. J. D. O., Hereijgers, M. J. M., Höfer, D., Lau, C., et al. (2025) · European Heart Journal Open · doi:10.1093/ehjopen/oeaf120 · Cited by 2
Self-citation
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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