Integrating pre-ablation and post-ablation B-type natriuretic peptide to identify high-risk population for long-term adverse events and arrhythmic recurrence in persistent atrial fibrillation

BACKGROUND: Pre-procedural and post-procedural plasma B-type natriuretic peptide (BNP) levels can predict rhythm outcomes after catheter ablation for atrial fibrillation (AF). However, the significance of long-term events remains unclear. Therefore, this study aimed to investigate the significance of integrating pre-ablation and post-ablation BNP levels on major adverse cardiovascular events (MACE) and arrhythmic recurrence in patients with persistent AF undergoing catheter ablation. METHODS: We analysed 392 patients who underwent first catheter ablation. Patients were stratified into four subgroups based on pre-ablation plasma BNP level and its relative change after ablation (ΔBNP) using their respective median values (pre-ablation BNP: 148.0 pg/mL, ΔBNP: -52.6%): Low-Low (pre-ablation<148.0 pg/mL, ΔBNP<-52.6%), Low-High (pre-ablation<148.0 pg/mL, ΔBNP≥-52.6%), High-Low (pre-ablation≥148.0 pg/mL, ΔBNP<-52.6%) and High-High (pre-ablation≥148.0 pg/mL, ΔBNP≥-52.6%). The primary endpoint was MACE, which included all-cause death, heart failure hospitalisation and other cardiovascular hospitalisations. The secondary endpoint involved arrhythmic recurrence. RESULTS: Of the 392 patients, 101 were classified as Low-Low, 91 as Low-High, 97 as High-Low and 103 as High-High. During a median follow-up of 5.3 (IQR: 3.2-7.2) years, 63 patients (16%) experienced MACE. Heart failure hospitalisation accounted for the majority of events (63%). The High-High subgroup showed significantly higher MACE rates than others (cumulative incidence (95% CI): 26.3% (16.2% to 35.2%), p<0.001). Low-High and High-High subgroups demonstrated a higher arrhythmic recurrence (p<0.001). After multivariate adjustment, the High-Low and High-High subgroups demonstrated progressively higher risks of MACE incidence compared with the Low-Low and Low-High subgroups. Both Low-High and High-High subgroups showed an elevated arrhythmic recurrence risk (both p<0.001). CONCLUSIONS: Integrating pre-ablation and post-ablation BNP levels can be useful for identifying patients with persistent AF at high risk of MACE and arrhythmic recurrence during long-term follow-up.