Aggressive Risk Factor Management Reduces AF Recurrence After Ablation: JAMA

Atrial fibrillation is still the most frequent cardiac arrhythmia, with recurrence rates still high after catheter ablation. Observational reports suggested that intense lifestyle modification, i.e., weight loss, blood pressure control, and control of metabolic risk factors, could ameliorate ablation outcome, but randomized clinical data were few. In response, a study was done using an open-label, multicenter randomized clinical trial in three centers in Adelaide, South Australia, to find the impact of LRFM on rhythm outcomes after AF ablation.

The trial was between July 2014 and September 2018 and followed participants for 12 months. A total of 122 patients with nonpermanent symptomatic AF, a body mass index (BMI) of 27 kg/m² or higher, and at least one additional cardiometabolic risk factor were enrolled. Participants were randomized equally into two groups: the LRFM group, which received structured, physician-led, individualized risk factor management, and the usual care (UC) group, which received standard clinical advice without structured intervention. Data were examined between September 2023 and August 2024.

All participants received first-time catheter ablation, mainly by pulmonary vein isolation, and both groups underwent guideline-directed AF treatment from clinicians who were blinded to treatment assignment. The main outcome assessed was the percentage of patients free of AF recurrence at 12 months after ablation.

The LRFM intervention included individualized treatments focusing on modifiable risk factors like obesity, hypertension, and metabolic dysbalance. Patients were provided with formal weight loss counselling, dietary advice, exercise prescription, and medical comorbidity optimization. The UC group received usual physician counsel without close follow-up or formal programs. This setup permitted estimation of the real additive value of dedicated lifestyle management on ablation outcomes.

Key Findings

• At 12 months, 61.3% in the LRFM group were AF-free recurrence compared with 40% in the UC group (P = 0.03).

• Hazard ratio for recurrent arrhythmia was 0.53 (95% CI, 0.32–0.89) and, therefore, a 47% reduced risk of recurrence with LRFM.

• Members of the LRFM group demonstrated a significant improvement in risk factor profile: mean body weight reduced by 9.0 kg (95% CI, −11.1 to −6.8 kg), waist circumference was reduced by 7.0 cm (95% CI, −9.4 to −4.5 cm), and systolic blood pressure was reduced by 10.8 mm Hg (95% CI, −16.1 to −5.5 mm Hg).

• Diastolic pressure gradients were small (−3.5 mm Hg; 95% CI, −7.2 to 0.2 mm Hg).

• Symptoms of AF were relieved more substantially in LRFM (mean difference, −2.0; 95% CI, −3.7 to −0.3) compared with UC.

In patients with AF, increased BMI, and one or more cardiometabolic risk factors, intensive lifestyle and risk factor management substantially decreased arrhythmia recurrence at 12 months of catheter ablation. These findings emphasize the imperative position of multicomponent lifestyle intervention programs for maintaining sinus rhythm and enhancing long-term AF ablation results.

Reference:

Pathak RK, Elliott AD, Lau DH, et al. Aggressive Risk Factor Reduction Study for Atrial Fibrillation Implications for Ablation Outcomes: The ARREST-AF Randomized Clinical Trial. JAMA Cardiol. Published online October 29, 2025. doi:10.1001/jamacardio.2025.4007