Key result
Female sex linked to ~39% lower post-ablation AF recurrence than male sex in lower-BMI patients.
Why the study?
The SUPPRESS-AF trial showed no significant overall reduction in 1-year atrial tachyarrhythmia recurrence with additional left atrial low-voltage-area (LVA) ablation versus pulmonary vein isolation alone in persistent AF with LVAs. Whether body mass index modifies sex differences in 1-year recurrence and LVA burden required clarification to understand outcome heterogeneity.
Does body mass index modify sex differences in 1-year atrial tachyarrhythmia recurrence and low-voltage-area burden in patients with persistent atrial fibrillation undergoing catheter ablation?
RCT (n=341)
1:1
Does body mass index modify sex differences in 1-year atrial tachyarrhythmia recurrence and low-voltage-area burden in patients with persistent atrial fibrillation undergoing catheter ablation?
In persistent AF patients with low-voltage areas undergoing ablation, women with lower BMI (<23.3 kg/m2) experienced significantly lower 1-year arrhythmia recurrence than men despite having a greater low-voltage substrate burden, whereas no sex difference was observed at higher BMI.
BMI modifies sex differences in post-ablation AF recurrence; leaves open differential benefit of substrate ablation in low-BMI women.
Background The SUPPRESS-AF randomised trial showed no significant overall reduction in 1-year atrial tachyarrhythmia recurrence with additional left atrial low-voltage-area (LVA) ablation versus pulmonary vein isolation (PVI) alone in persistent atrial fibrillation (AF) with LVAs, underscoring the need to understand outcome heterogeneity. Purpose To assess whether body mass index (BMI) modifies sex differences in 1-year recurrence and LVA burden. Methods Subgroup analysis of 341 participants with persistent AF and LVAs covering >=5 cm2 of the left atrial surface on a post-PVI voltage map, randomised 1:1 to PVI plus LVA ablation or PVI alone. LVAs were defined by bipolar voltage <0.5 mV. AF/atrial tachycardia (AT) recurrence was assessed by scheduled 24 h Holter monitoring at 6 and 12 months and twice-daily portable electrocardiogram recordings from 6 to 12 months. The primary endpoint was AF/AT recurrence or initiation of antiarrhythmic drugs within 12 months after ablation (90-day blanking period). BMI was dichotomised at the median (23.3 kg/m2); exploratory BMI bands were <21, 21-<23, and >=23 kg/m2. Results Of 341 patients, 167 were women. In the lower-BMI stratum (<23.3 kg/m2; n=169), 1-year recurrence was lower in women than men (36% vs 52%; log-rank P=0.034; hazard ratio 0.61, 95% CI 0.38-0.98). In the higher-BMI stratum (>=23.3 kg/m2; n=172), recurrence did not differ by sex (46% vs 42%; P=0.83). In the lower-BMI stratum, women had smaller left atrial surface area but greater LVA burden than men (surface area 143.9 [124.8-174.7] vs 154.9 [134.9-184.7] cm2, P=0.030; LVA area 17.8 [10.1-26.7] vs 12.0 [8.1-20.8] cm2, P=0.006; LVA area percentage 11.3 [6.9-19.7] vs 7.3 [5.4-12.0]%, P<0.001). In exploratory BMI bands, the sex difference was most pronounced at BMI 21-<23 (27% vs 55%; P=0.014) and absent at BMI <21 and >=23. Conclusion In persistent AF patients with LVAs, sex differences in 1-year recurrence were confined to lower BMI, despite a greater voltage-defined substrate burden in women. BMI-dependent sex-specific mechanisms beyond LVA extent may contribute to outcome heterogeneity and support phenotype-driven risk stratification in LVA-positive persistent AF.
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Tanaka et al. (2026) conducted an RCT in Persistent atrial fibrillation with left atrial low-voltage areas (n=341). Female sex stratified by BMI (in patients randomised to PVI plus LVA ablation or PVI alone) vs. Male sex stratified by BMI was evaluated on AF/AT recurrence or initiation of antiarrhythmic drugs within 12 months after ablation (after a 90-day blanking period) (HR 0.61, 95% CI 0.38-0.98, p=0.034). Female sex was associated with lower 1-year AF/AT recurrence than male sex at BMI <23.3 kg/m2 (36% vs 52%; HR 0.61; 95% CI 0.38-0.98; P=0.034), but not at BMI >=23.3 kg/m2 (46% vs 42%; P=0.83).
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