Clinical and socioeconomic inequalities in access to catheter ablation of atrial fibrillation: a nationwide cohort study, spanning 15 years

Background/Introduction Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia globally and catheter ablation reduces AF burden, improves symptoms and quality of life, and may improve long-term outcomes in selected patients. However, whether access to catheter ablation may be influenced by comorbidity burden and socioeconomic status (SES) remains unclear. Purpose We aimed to investigate if comorbidity profiles and SES differ between patients selected for catheter ablation and the general AF population. Methods We conducted a retrospective cohort study using data from linked Swedish national registers. The study population included 58,593 patients with AF, of whom 5,912 (10.1%) underwent catheter ablation between 2005 and 2019, matched by age and sex to 52,681 population-based controls. Comorbidity was assessed using the adapted Charlson Comorbidity Index (CCI) for register-based research in Sweden and the CHA2DS2-VA score. Vulnerability was defined as high level of comorbidity (CCI≥2), or low SES, comprising low income (1st quartile per corresponding 5-year period), or low education (up to elementary school). Logistic regression was used to evaluate the association between low SES, vulnerability and ablation status. Calendar period (2005–2009, 2010–2014, 2015–2019), and SES- and vulnerability–by–period interaction terms were included to evaluate whether this association changed over time. Results In the AF cohort (N=58,593), the mean age was 61.3 ± 9.9 years (median 63 years), and 30.6% were women. Patients undergoing AF ablation had a lower comorbidity burden (mean adapted CCI score 0.7 vs. 1.1, p<0.001; CHA2DS2-VA 1.3 vs. 1.7, p<0.001), while they presented with higher income (median 286 vs. 207 thousand Swedish kronor/year, p<0.001), and fewer with low education level (15.2% vs. 26.2%, p<0.001). Fewer ablated patients had low SES as compared to non-ablated patients (31.0% vs. 44.5% in 2005–2009, 26.0% vs. 42.2% in 2010–2014, and 24.7% vs. 42.3% in 2015–2019), with a widening trend over time (p<0.001 for trend between 2005-2009 and 2015-2019). Overall vulnerability was significantly lower in ablated patients as compared to non-ablated patients (40.5% vs. 53.8% in 2005–2009, 38.4% vs. 55.7% in 2010–2014, and 37.9% vs. 61.0% in 2015–2019), also with a widening trend over time (p<0.001 for trend between 2005-2009 and 2015-2019). Conclusions In this nationwide cohort of patients with AF, socioeconomic and clinical vulnerability were associated with a lower likelihood of receiving catheter ablation. These disparities increased over time, suggesting growing inequalities in access to AF ablation despite expansion of the procedure and a universal healthcare setting. Our findings highlight the need for strategies to ensure equitable access to AF ablation.Figure 1Graph