Prevalence and Impact of Poorly Controlled Modifiable Risk Factors Among Patients Who Underwent Atrial Fibrillation Ablation

https://doi.org/10.1016/j.amjcard.2023.04.024Get rights and content

Managing atrial fibrillation (AF) risk factors (RFs) improves ablation outcomes in obese patients. However, real-world data, including nonobese patients, are limited. This study examined the modifiable RFs of consecutive patients who underwent AF ablation at a tertiary care hospital from 2012 to 2019. The prespecified RFs included body mass index (BMI) ≥30 kg/m2, >5% fluctuation in BMI, obstructive sleep apnea with continuous positive airway pressure noncompliance, uncontrolled hypertension, uncontrolled diabetes, uncontrolled hyperlipidemia, tobacco use, alcohol use higher than the standard recommendation, and a diagnosis-to-ablation time (DAT) >1.5 years. The primary outcome was a composite of arrhythmia recurrence, cardiovascular admissions, and cardiovascular death. In this study, a high prevalence of preablation modifiable RFs was observed. More than 50% of the 724 study patients had uncontrolled hyperlipidemia, a BMI ≥30 mg/m2, a fluctuating BMI >5%, or a delayed DAT. During a median follow-up of 2.6 (interquartile range 1.4 to 4.6) years, 467 patients (64.5%) met the primary outcome. Independent RFs were a fluctuation in BMI >5% (hazard ratio [HR] 1.31, p = 0.008), diabetes with A1c ≥6.5% (HR 1.50, p = 0.014), and uncontrolled hyperlipidemia (HR 1.30, p = 0.005). A total of 264 patients (36.46%) had at least 2 of these predictive RFs, which was associated with a higher incidence of the primary outcome. Delayed DAT over 1.5 years did not alter the ablation outcome. In conclusion, substantial portions of patients who underwent AF ablation have potentially modifiable RFs that were not well controlled. Fluctuating BMI, diabetes with hemoglobin A1c ≥6.5%, and uncontrolled hyperlipidemia portend an increased risk of recurrent arrhythmia, cardiovascular hospitalizations, and mortality after ablation.

Section snippets

Methods

Medical records and procedure notes were retrospectively reviewed for consecutive patients who underwent AF ablation at the University of Nebraska Medical Center in Omaha, Nebraska between 2012 and 2019. All patients were aged ≥19 years and had at least 1 cardiac monitor after a 3-month blanking period. This work was approved by the University of Nebraska Medical Center Institutional Review Board under protocols 0054-22-EP and 0576-20-EP.

Baseline characteristics, CHA2DS2-VASc score (congestive

Results

The preablation baseline characteristics of the 724 patients are listed in Table 1. The mean age at the index ablation was 61.9 ± 10.3 years and 32.5% were women. Most of the study patients had persistent AF (72.2%) and 18.1% had undergone a previous catheter ablation. The mean baseline CHA2DS2VASc score was 2.4 ± 1.6. Common co-morbidities included hypertension (63.4% of participants), congestive heart failure (33.4%), diabetes mellitus (18.1%), and previous cardiovascular accidents (7.2%).

Discussion

In this retrospective study from a tertiary care center, we observed that poorly controlled modifiable RFs were highly prevalent among patients with AF referred for catheter ablation. Uncontrolled or untreated RFs, specifically a fluctuation in BMI >5%, diabetes mellitus with hemoglobin A1c ≥6.5%, and uncontrolled hyperlipidemia were associated with a 1.3 to 1.5 times increased risk of recurrent AF, cardiovascular admissions, or cardiovascular death. In addition, excessive alcohol use was

Acknowledgment

The authors thank James Aguto, BS, for his assistance with data collection.

Disclosures

The remaining authors have no conflicts of interest to declare. Drs. Stout and Naksuk take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

References (45)

  • MH Kim et al.

    Estimation of total incremental health care costs in patients with atrial fibrillation in the United States

    Circ Cardiovasc Qual Outcomes

    (2011)
  • AN Ganesan et al.

    Long-term outcomes of catheter ablation of atrial fibrillation: a systematic review and meta-analysis

    J Am Heart Assoc

    (2013)
  • S Mohanty et al.

    Long-term outcome of catheter ablation in atrial fibrillation patients with coexistent metabolic syndrome and obstructive sleep apnea: impact of repeat procedures versus lifestyle changes

    J Cardiovasc Electrophysiol

    (2014)
  • DS Chew et al.

    Diagnosis-to-ablation time and recurrence of atrial fibrillation following catheter ablation: A systematic review and meta-analysis of observational studies

    Circ Arrhythm Electrophysiol

    (2020)
  • RM Lang et al.

    Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging [published correction appears in Eur Heart J Cardiovasc Imaging 2016;17:412] [published correction appears in Eur Heart J Cardiovasc Imaging 2016;17:969]

    Eur Heart J Cardiovasc Imaging

    (2015)
  • LG Snetselaar et al.

    Dietary guidelines for Americans, 2020–2025: understanding the scientific process, guidelines, and key recommendations

    Nutr Today

    (2021)
  • TS Potpara et al.

    Cohort profile: the ESC EURObservational Research Programme Atrial Fibrillation III (AF III) Registry

    Eur Heart J Qual Care Clin Outcomes

    (2021)
  • P Kirchhof et al.

    Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention oF thromboemolic events–European Registry in atrial fibrillation (PREFER in AF)

    Europace

    (2014)
  • HS Abed et al.

    Effect of weight reduction and cardiometabolic risk factor management on symptom burden and severity in patients with atrial fibrillation: a randomized clinical trial

    JAMA

    (2013)
  • EJ Benjamin et al.

    Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham heart study

    JAMA

    (1994)
  • P Palm et al.

    Educational interventions to improve outcomes in patients with atrial fibrillation-a systematic review

    Int J Clin Pract

    (2020)
  • G Thrall et al.

    Quality of life in patients with atrial fibrillation: a systematic review

    Am J Med

    (2006)
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