Catheter ablation for atrial fibrillation in patients with heart failure with preserved ejection fraction

Atrial fibrillation (AF) and heart failure (HF) with preserved ejection fraction (HFpEF) are prevalent and frequently coexisting cardiovascular disorders, significantly contributing to morbidity and mortality worldwide. In patients with HFpEF, the presence of AF is associated with increased mortality, thromboembolic risk, and hospitalization rates. Although in HF with reduced ejection fraction (HFrEF) catheter ablation (CA) for AF has been shown to reduce the composite endpoint of all-cause death or hospitalization for worsening HF compared with medical therapy alone1, data supporting its efficacy in HFpEF remain limited and often contradictory. Therefore, we sought to evaluate the efficacy of CA in a large sample of patients with HFpEF.

We conducted a retrospective cohort study using de-identified, aggregate patient data from the TriNetX research network, which includes data from 103 healthcare organizations and approximately 110 million patients. Patients aged ≥18 years with a history of HFpEF and paroxysmal or persistent AF on rate and/or rhythm control therapy, between January 2016 and January 2020 were identified. Patients were divided into two groups based on whether they underwent CA for AF or not. Following a 1:1 propensity score matching for AF subtype, baseline demographics, prescribed medications (notably GDMT, rate/rhythm control strategies and anticoagulation), comorbidities, LVEF and NT-proBNP/BNP levels, we calculated ORs and Cox proportional HRs to compare outcomes over a two-year follow-up period. The primary end point was a composite of death from any cause or hospitalization for acute HF exacerbation (ICD codes/need for IV diuretics). The secondary outcomes included stroke and ED visit for any cause.

The matched cohort included 2,088 patients with HFpEF (n=1,044 per group; mean age: 71.7 years; 49.5% female; 83% white; mean LVEF: 55.3%; 75.5 % paroxysmal AF; 24.5 % permanent AF). After a median follow-up of 17.2 months the primary composite end point occurred in significantly fewer patients in the CA group (28.6%) than in the non-CA group (42.2%) (OR: 0.549 [95% CI: 0.46-0.66]; P < 0.0001). Stroke was less frequent in patients who underwent CA (4.5% vs 6.8% OR: 0.655 [95% CI: 0.46-0.94]; P = 0.02). ED visits were similar in the two groups (OR: 0.989 [95% CI: 0.83-1.17]; P = 0.89). Time-to-event analysis also demonstrated the benefits of CA (Figure).

Catheter ablation for AF in patients with HFpEF was associated with a significantly lower rate of a composite end point of death from any cause or hospitalization for acute HF exacerbation than was medical therapy alone. Further prospective studies are needed to strenghen this association.

Time to event analysis of outcomes