Abstract

BACKGROUND: Atrial fibrillation (AF) ablation is Class I recommendation in selected heart failure (HF) patients with reduced ejection fraction; less is known in heart failure with preserved ejection fraction (HFpEF). OBJECTIVES: The aim of this study was to investigate the effects of AF ablation in patients with HFpEF. METHODS: The CABANA (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial randomized patients with cardiovascular risk factors for stroke to AF ablation vs drug therapy. The presence of a high likelihood of HFpEF at enrollment was determined by a modified H₂FPEF score of ≥6. Treatment effects of baseline HFpEF likelihood on the AF ablation for death and cardiovascular admission, AF recurrence, and functional status were assessed. RESULTS: A total of 1,763 patients were included in the analysis. A high modified H₂FPEF score (55% of the entire cohort) resulted in a significant treatment effect modulation (P for interaction = 0.027), with a lower risk for cardiovascular hospitalization or death in patients with a high likelihood of HFpEF (HR: 0.82 [95% CI: 0.69-0.98]; P = 0.025), but not in patients without (HR: 1.00 [95% CI: 0.82-1.22]; P = 0.987). Although patients with a high likelihood of HFpEF were at a higher risk for AF recurrence, the greatest treatment effect of AF ablation on AF recurrence was observed in patients with a high likelihood of HFpEF (P for interaction = 0.035). In a sensitivity analysis in a subset of patients with echocardiographic evidence of HFpEF (n = 225), a similar treatment interaction was found. CONCLUSIONS: In patients undergoing AF ablation, the presence of underlying HFpEF (either by HFpEF probability or defined by echocardiography) was associated with a larger benefit with AF ablation on clinical outcome, AF recurrence, and functional status. (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation [CABANA]; NCT00911508).