Background: 

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are both common conditions that frequently coincide, aggravating the patients’ morbidity and mortality. To date no specific treatment strategy for patients with concomitant AF and HFpEF exists. We recently demonstrated that catheter ablation (CA) for AF in HFpEF patients induces reverse remodeling and improves heart failure symptoms. However, a study comprehensively comparing the effects of CA and medical therapy on HFpEF patients is missing.

Aim:

The aim of this study was to compare outcome of CA for AF to medical therapy in patients with HFpEF.

Methods:

We included all AF patients with diagnosis of HFpEF according to the current guidelines treated at our hospital between 2013 and 2018. The primary endpoint was a composite of the time to death or heart failure hospitalization. Secondary endpoints were a composite of time to death or all-cause hospitalization, time to death, heart failure symptoms as measured by NYHA class, plasms NT-pro BNP levels, and reassessment of echocardiographic and clinical HFpEF diagnostic criteria.

Results:

Between January 2013 and December 2018, 6614 AF patients were treated at our tertiary care center. Of those, 752 patients had echocardiographic diastolic dysfunction. By implementation of the current ESC HFpEF criteria, we identified 127 patients with confirmed HFpEF. After a mean follow-up of 35 ± 22 months, significantly less patients in the CA group had recurrence of atrial arrhythmia (HR: 0.47; 95% CI: 0.25-0.87; p=0.016). Moreover, significantly less patients in the CA group showed progression from paroxysmal to persistent AF (CA: 1 out of 26 patients; medical therapy: 6 out of 22 patients; p=0.038). Time to first heart failure hospitalization or death was significantly longer in the CA group compared to the medical therapy group (HR: 0.30; 95% CI: 0.13-0.67; p=0.003). ). This was driven solely by a decrease in heart failure hospitalization. For the secondary outcomes, both, cardiovascular hospitalization (HR: 0.53; 95% CI: 0.30-0.95; p=0.034), and all-cause hospitalization (HR: 0.56; 95% CI:0.33-0.96; p=0.033) were also significantly less frequent in the CA group. Additionally, clinical and echocardiographic parameters of HFpEF, such as NT-pro BNP serum levels, E/E’ ratio, and left ventricular mass index improvedsignificantly after CA but not upon medical therapy.

Conclusion:

This is the first study evaluating the effects of CA for AF in comparison to medical therapy in patients with concomitant HFpEF. CA, but not medical therapy, led to an improvement of diastolic function, heart failure symptoms and a reduction in heart failure hospitalizations. As a result, AF ablation should be considered in patients with HFpEF and concomitant AF.