Sex-based differences in the atrial fibrillation care pathway and outcomes: an ITHACA-database analysis

AIMS: To characterize sex-specific differences in clinical presentation, evaluate progression through the atrial fibrillation (AF) care pathway from diagnosis to catheter ablation (CA) and assess long-term outcomes. METHODS AND RESULTS: This was a retrospective cohort study of patients with incident AF at Northwell Health between 2015 and 2024 from the ITHACA-database. Sex-specific differences in clinical presentation were examined. The AF care pathway was operationalized as a stepwise cascade, modelling conditional drop-off to identify care gaps. Sex-specific CA risk ratios were assessed via Poisson regression. Incident AF was identified among 165 563/655 459 patients (71.4 ± 11.6 years, 32% non-white, 45% female) with a recorded diagnosis of AF. Women were older (73.3 ± 10.6 vs. 69.8 ± 12.1 years, P < 0.001), had higher rates of dementia (9.1% vs. 5.2%), stroke (8.6% vs. 7.4%) and congestive heart failure (21.5% vs. 20.8%) at diagnosis. Transfer-of-care gaps [median 3.6 years follow-up, 96% retention] were identified at every level: 31.5% of women vs. 35.3% of men were evaluated by cardiology, 16.2% vs. 21.6% by electrophysiology, and 3.5% vs. 5.7% underwent CA (all P < 0.001). Women were 16% less likely to receive CA (RR 0.84 95% CI 0.77-0.91). In cause-specific Cox models, female sex was associated with incident stroke (aHR 1.24, 95% CI 1.18-1.30) and dementia (aHR 1.30, 95% CI 1.24-1.35), but modestly lower mortality after adjustment (aHR 0.96, 95% CI 0.94-0.99). CONCLUSION: In this real-world analysis, significant sex-specific differences in clinical phenotype at presentation, progression through the AF care pathway and clinical outcomes were observed.