Impact of early catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction—real-world evidence

INTRODUCTION: Catheter ablation for atrial fibrillation (AF) has been shown to reduce mortality and heart failure (HF) progression in patients with AF and HF with reduced ejection fraction; however, outcomes in HF with preserved ejection fraction (HFpEF), especially the optimal timing of ablation, remain uncertain. OBJECTIVES: To evaluate long-term outcomes of catheter ablation in patients with AF and HFpEF based on the temporal correlation between the AF diagnosis and the ablation procedure utilizing real-world data. METHODS: In this observational cohort study using the U.S. Collaborative Network in TriNetX, adults with AF and HFpEF between October 2018 and October 2024 were identified. After 1:1 propensity score matching, 5550 patients were included. The primary endpoint was a composite of cardioversion, new antiarrhythmic drug (AAD) therapy, or repeat AF ablation after a 3-month blanking period. Secondary endpoints included hospitalization, mortality, HF exacerbation, and AAD use up to 4 years of follow-up. Outcomes were compared between patients undergoing ablation within 1 year of AF diagnosis and those having ablation after 1 year. RESULTS: Over a mean follow-up of 742 ± 489 days, early AF ablation was associated with lower risks of the primary endpoint (hazard ratio (HR) 0.81, 95% CI 0.76-0.87, p < 0.001), reduced hospitalization (HR 0.77, 95% CI 0.70-0.87, p < 0.001), and lower AAD Class I or III use (HR 0.82, 95% CI 0.77-0.88, p < 0.001). No significant differences were observed in HF exacerbations (HR 0.99, 95% CI 0.89-1.00, p = 0.950) or mortality (HR 1.18, 95% CI 0.91-1.53, p = 0.211). CONCLUSION: Early catheter ablation was associated with a decreased all-cause hospitalization and AF recurrence in HFpEF patients but did not reduce HF exacerbations or mortality.