Background. Atrial fibrillation (AF) ablation is class I recommendation in selected heart failure patients with reduced ejection fraction, less is known in heart failure with preserved ejection fraction (HFpEF).

Objective. To investigate the effects of AF ablation in patients with HFpEF.

Methods. The CABANA trial randomized 1,763 patients with cardiovascular risk factors for stroke to AF ablation versus drug therapy. Presence of a high likelihood of HFpEF at enrollment was determined by a modified H₂FPEF score ≥6. Treatment effects of baseline HFpEF likelihood on the AF ablation for death and cardiovascular (CV) admission, AF recurrence and functional status were assessed.

Results. A high modified H₂FPEF score (55% of the entire cohort) resulted in a significant treatment effect modulation (p for interaction= 0.027), with a lower risk for CV hospitalization or death in patients with a high likelihood of HFpEF (HR= 0.82, 95%CI 0.69-0.98, p=0.025) but not in patients without (HR 1.00, 95%CI 0.82-1.22, p=0.987). Despite that patients with a high likelihood of HFpEF were a higher risk for AF recurrence, the largest treatment effect of AF ablation on AF recurrence was observed in patients with a high likelihood of HFpEF (p for interaction= 0.035). In sensitivity analysis in a subset with echocardiographic evidence of HFpEF (n=225), similar treatment interaction was found.

Conclusion. In patients undergoing AF-ablation, the presence of underlying HFpEF (either by HFpEF probability or defined by echocardiography) was associated with a larger benefit with AF ablation on clinical outcome, AF recurrence and functional status.

Editors

JACC Heart Failure Editor-in-Chief
Biykem Bozkurt, MD, PhD, FACC 

Deputy Editor
Akshay S. Desai, MD, MPH 

JACC Heart Failure CME/MOC Editor
Kenneth A. Ellenbogen, MD

Author
Bhaskar Arora, MD, FACC

Important Dates

Date of Release: May 5, 2025
Term of Approval/Date of CME/MOC Expiration: May 4, 2026