Aggressive BP Control on the Recurrence of AF After Catheter Ablation

Study Questions:

What is the role of aggressive blood pressure (BP) control in patients undergoing catheter ablation for atrial fibrillation (AF)?

Methods:

This is a randomized, open-label trial evaluating the effect of aggressive BP control on the recurrence of AF in patients with high symptom burden who are undergoing catheter ablation. A total of 184 patients with AF with BP >130/80 mmHG were randomized prior to their ablation procedures to either aggressive BP lowering (target of 120/80 mmHg) or a standard BP target of <140/90 mmHg.

Results:

The results at 6 months demonstrated a mean systolic BP in the aggressive group of 123.2 ± 13.2 mmHg compared with 135.4 ± 15.7 mmHg for the standard BP group (p < 0.001). The primary outcome of symptomatic recurrence of atrial tachycardia (AT), AF, or atrial flutter (AFL) that occurred more than 3 months post ablation of a duration longer than 30 seconds occurred in 54 (61.4%) patients in the aggressive group compared with 52 (61.2%) in the standard group (95% confidence interval; 0.65-1.38; p = 0.763). Median follow-up was 14 months. The secondary endpoint (any recurrent AT/AF/AFL post ablation, including those with or without symptoms; AF-related hospitalizations; emergency department visits related to AF; thromboembolic events; or recurrent ablation) was not significant between the two groups except that AF-related emergency department visits occurred more frequently in patients in the aggressive group (30.4%) compared with the standard group (17.4%) (p = 0.046). Among prespecified subgroups, there was a significant difference in the primary outcome event rate in those aged >61 years in the aggressive group (hazard ratio 0.58; 95% confidence interval 0.34-0.97; p = 0.013). There was also a significant difference in adverse effects between the 2 treatment groups. Hypotension that required modification in therapy occurred in 26% of patients in the aggressive group compared with 0 in the standard group. Additionally, there were more emergency department visits in the aggressive group (2.2%) for hypotension compared with the standard group (0%).

Conclusions:

Aggressive BP control in patients with AF and high symptom burden does not reduce the recurrence rate following catheter ablation. However, aggressive BP control does result in a significantly high risk of hypotension requiring medication adjustments.

Perspective:

Given the overall burden of AF and the relatively high recurrence rates despite ablation, it is important to continue to evaluate parameters that, when modified, may reduce this risk. Although aggressive BP control would, in the grand scheme of things, be a relatively easy strategy to implement, it unfortunately does not appear to reduce the recurrence rate based on this study but instead may in fact increase harm due to significant hypotension. Therefore, ongoing evaluation of other factors that may play a role in the recurrence of AF is needed.


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