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Journal of the American College of Cardiology

Clinical Articles, Featured

AF ablation improves exercise in heart-failure

Radiofrequency catheter ablation of atrial fibrillation (AF) is superior to rate control for improving exercise performance in individuals with heart failure, according to a study published recently in the Journal of the American College of Cardiology.1

The study included 52 patients, with 26 randomised to catheter ablation and 26 to contemporary standard-of-care rate control with beta-blockers and/or digoxin (<80 beats per minute at rest and <110 beats per minute after the six-minute-walk test). At 12 months, 88% of the ablation patients were in normal sinus rhythm and 96% of patients achieved rate control.

The primary end point was assessment of exercise capacity as measured by peak oxygen consumption (VO2), which increased 2.13 mL/kg/min in the catheter-ablation arm compared with a reduction of 0.94 mL/kg/min in the rate-control arm. The benefit of catheter ablation emerged over time, with no difference in peak oxygen consumption evident at three months.

Dr Tom Wong (Royal Brompton & Harefield NHS Foundation Trust)

Dr Tom Wong (Royal Brompton & Harefield NHS Foundation Trust)

Regarding secondary end points, scores on the Minnesota Living with Heart Failure Questionnaire were also significantly improved at six and 12 months among those treated with ablation compared with rate control. Brain natriuretic peptide (BNP) levels were significantly reduced at six and 12 months in the ablation arm. There was also a trend toward improvement in the six-minute-walk test at 12 months as well as a trend toward an improvement in ejection fraction.

Co-author, consultant cardiologist Dr Tom Wong (Royal Brompton & Harefield NHS Foundation Trust, London), spoke to BJC Arrhythmia Watch on AF, and the study’s implications for patients in the UK: “AF is common in patients with heart failure, its prevalence rising from 10% in mildly symptomatic heart failure towards 50% in severely symptomatic heart failure patients. AF in patients with heart failure not only significantly worsens exercise tolerance and quality of life, but also increases the risk of stoke, hospitalisation and mortality,” he said.

“This is the first randomised control trial showing physiological benefit (assessed by cardiopulmonary exercise performance) of catheter ablation compared with rate control in this group of patients. It is important to note that the ablation procedures in this group of patients with persistent AF are often long, and not without risk, and are probably best performed in high volume experienced centres at least for the time being,” Dr Wong continued.

“However, evidence from this study would suggest that aiming for – and achieving – sinus rhythm, rather than accepting AF with a rate-control strategy, could be beneficial in patients with AF heart failure. At present, ablation appears best-placed to achieve this given that existing pharmacological rhythm-control options have not shown overall benefit,” he concluded.

In an accompanying editorial,2 Dr Mark O’Neill (St Thomas’ Hospital, London, UK) highlights the study’s general relevance, noting the patients were young and two-thirds had nonischaemic heart failure. Also, just over 50% of the patients in both treatment arms had undergone a previous cardioversion. Regarding adverse events, he points out that four patients had procedural complications, with one patient requiring a sternotomy for tamponade.

“Although the reported maintenance of sinus rhythm at one year is high, gradual attrition will likely occur as has been widely reported for patients with persistent AF, necessitating a very frank and thorough discussion with patients at the outset about the potential risk and unproven longer-term benefits of such an aggressive interventional strategy,” said Dr O’Neill.


1. Jones DG, Haldar SK, Hussain W, et al. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure (ARC-HF). J Am Coll Cardiol 2013.

2. O’Neill MD. Heart failure, atrial fibrillation, and catheter ablation: Are we there yet? J Am Coll Cardiol 2013; available at:

Published on: March 27, 2013

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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