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Aggressive Risk Factor Reduction Study for Atrial Fibrillation and Implications for the Outcome of Ablation: The ARREST-AF Cohort Study | Journal Scan
Study Questions:
Does aggressive risk factor management (RFM) improve outcomes after catheter ablation of atrial fibrillation (AF)?
Methods:
Aggressive risk factor management (RFM) was offered to 149 patients (with a body mass index [BMI] ≥27 kg/m2 and one other cardiac risk factor) undergoing catheter ablation of AF in the ARREST-AF study. The goal blood pressure (BP) was <130/80 mm Hg, with the additional requirement of resolution of left ventricular hypertrophy on echocardiography. For body weight, the goal was 10% reduction and a BMI ≤25 kg/ m2 and included 200 minutes/week of moderate exercise. Additional goals included low-density lipoprotein cholesterol <100 mg/dl, glycated hemoglobin ≤6.5%, continuous positive airway pressure (CPAP) treatment, smoking cessation, and moderation of alcohol intake. Patients who accepted RFM constituted the intervention group (n = 61), and those that refused, the control group (n = 88). The electrophysiologist performing the ablation procedure was blinded to group assignment.
Results:
There was a greater decline in systolic BP (34 vs. 21 mm Hg), body weight (-13 vs. -2 kg), better lipid profiles and glycemic control, and lower apnea-hypopnea index and better compliance with CPAP in patients in the RFM group. Smoking cessation rates and alcohol intake were similar between the two groups. Evidence of reverse remodeling on echocardiography was more pronounced in the intervention group. Arrhythmia-free survival was significantly greater in the RFM group. This was also accompanied by improvement in symptom scores. On multivariable analysis, AF type and RFM were independent predictors of outcome.
Conclusions:
The authors concluded that aggressive RFM is associated with an improvement in long-term outcomes after catheter ablation of AF.
Perspective:
AF, even in patients with no obvious heart disease, is accompanied by an abnormal atrial substrate. Although catheter ablation is effective in eliminating AF in the majority of patients, long-term studies have documented late attrition. It is likely that ongoing and sometimes unidentified processes continue to exact a toll on the substrate, leading to arrhythmia recurrence. This should not be surprising since catheter ablation does not arrest this process. This nicely done study demonstrates the incremental benefit of aggressive management of risk factors that likely contribute to an impaired substrate. Whether these interventions and lifestyle changes can be sustained on a long-term basis is unknown.
Keywords: Alcohols, Apnea, Atrial Fibrillation, Body Mass Index, Body Weight, Catheter Ablation, Cholesterol, LDL, Continuous Positive Airway Pressure, Echocardiography, Heart Atria, Heart Conduction System, Hemoglobin A, Hypertrophy, Risk Factors, Smoking Cessation
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