Phased withdrawal of guideline-directed medical therapy after AF ablation resulted in heart failure deterioration in 13.0% of patients compared to 0% with continuation (P=0.11).
RCT (n=50)
Open-label
1:1
No
Does phased GDMT withdrawal increase heart failure deterioration compared to GDMT continuation in patients with recovered AF-mediated cardiomyopathy after catheter ablation?
In patients with recovered AF-mediated cardiomyopathy post-ablation, withdrawing GDMT led to a non-significant 13% rate of HF deterioration but avoided drug-related adverse events seen with continuation.
Absolute Event Rate: 13% vs 0%
p-value: p=0.11
Importance Withdrawal of guideline-directed medical therapy (GDMT) for heart failure (HF) is common after atrial fibrillation (AF) catheter ablation and recovery of cardiac function, but safety remains uncertain. Objective To assess the feasibility and safety of phased GDMT withdrawal in patients with AF with highly suspected AF-mediated cardiomyopathy after catheter ablation. Design, Setting, and Participants This open-label pilot randomized clinical trial included adult patients who were enrolled and randomized from April 13, 2023, to September 19, 2024, at Beijing Anzhen Hospital, China, with a 6-month follow-up. Eligible patients were those with suspected AF-mediated cardiomyopathy at 3 months after ablation, defined by sinus rhythm at 3 months after ablation, absence of other suspected cardiomyopathies, improvement of left ventricular ejection fraction (LVEF) from 45% or less to 55% or more, normalized LV end-diastolic diameter (LVEDD), N-terminal pro–brain natriuretic peptide (NT-proBNP) levels less than 250 ng/L, and no HF symptoms or signs. Interventions Patients were randomly assigned in a 1:1 ratio to phased GDMT withdrawal or GDMT continuation. Main Outcomes and Measures The primary end point was HF deterioration, defined as LVEF decline more than 10% to less than 55%, LVEDD increase more than 10% and beyond normal, NT-proBNP levels doubling to more than 400 ng/L, or worsening HF signs or symptoms. Secondary outcomes included cardiovascular events, changes in echocardiographic and cardiac magnetic resonance (CMR) parameters, NT-proBNP levels, Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) scores, atrial arrhythmia recurrence, and adverse drug events. Results Among 50 patients enrolled and randomized, 47 completed follow-up (median IQR age, 56.0 48.0-60.5 years; 37 males 78.7%), including 23 (48.9%) in the GDMT withdrawal group and 24 (51.1%) in the continuation group. HF deterioration occurred in 3 patients with GDMT withdrawal (13.0%) and 0 with GDMT continuation (0%) ( P = .11). Early GDMT reinitiation in 3 patients with HF deterioration showed recovery of LVEF or NT-proBNP. No cardiovascular events occurred. Median (IQR) echocardiographic (LVEF: 0% −3.0% to 3.5% vs 1.5% −5.0% to 5.0%), CMR (LVEF: −2.1% −7.2% to 4.6% vs 2.9% −2.6% to 7.4%), and KCCQ-12 score (0 0 to 0.5 vs 0) changes were similar between groups. Median (IQR) NT-proBNP levels declined more in the GDMT continuation group than the withdrawal group (−25.7 −33.6 to −6.7 pg/mL vs 2.7 −21.4 to 24.2 pg/mL; P = .03). Adverse drug events were more frequent in the GDMT continuation group than the withdrawal group (5 20.8% vs 0 0%; P = .050). Arrhythmia recurrence rates were comparable (GDMT withdrawal: 3 13.0% vs continuation: 3 12.5%). Conclusions and Relevance In this pilot randomized clinical trial of carefully selected patients with AF with normalized cardiac function and sinus rhythm after catheter ablation, 13% of patients with GDMT withdrawal experienced HF deterioration, whereas drug-related complications were more common in the continuation group, suggesting that further studies are needed to determine whether GDMT can be safely discontinued in this population. Trial Registration Chinese Clinical Trial Registry Identifier: ChiCTR2300077439
“Given the relatively small sample size and the heterogeneity of populations with AFib and HF, these findings should be interpreted carefully and not generalized to broader populations with AFib or HF with reduced ejection fraction.”
This pilot randomized trial addresses the important clinical question of whether to continue or withdraw heart failure medications after successful AF ablation and recovery of cardiac function. The findings, though from a small study, are generating debate about the management of this patient population.
Li et al. (Fri,) conducted a rct in Atrial fibrillation with suspected AF-mediated cardiomyopathy (n=50). Phased guideline-directed medical therapy (GDMT) withdrawal vs. GDMT continuation was evaluated on Heart failure deterioration (LVEF decline >10% to <55%, LVEDD increase >10% and beyond normal, NT-proBNP doubling to >400 ng/L, or worsening HF signs/symptoms) (p=0.11). Phased withdrawal of guideline-directed medical therapy after AF ablation resulted in heart failure deterioration in 13.0% of patients compared to 0% with continuation (P=0.11).