Aggressive Risk Factor Management Reduced Recurrent AF by Nearly Half After Catheter Ablation

A structured, physician-led program targeting multiple cardiac risk factors substantially reduced atrial fibrillation recurrence in the year following catheter ablation, according to results from the ARREST-AF randomized clinical trial published in JAMA Cardiology.1

Among 122 patients with symptomatic AF undergoing first-time ablation, 61% of those receiving intensive lifestyle and risk factor modification (LRFM) remained free from atrial arrhythmia at 12 months, compared with 40% receiving usual care—representing a 47% reduction in recurrence risk (HR 0.53, 95% CI 0.32-0.89, P =.03).1

AF Recurs in Nearly Half of Patients

AF represents the most common clinically significant arrhythmia, and its development is driven largely by modifiable cardiac risk factors including hypertension, diabetes, obesity, and obstructive sleep apnea. While catheter ablation effectively treats AF and reduces burden, more than 45% of patients experience recurrent AF within 12 months when continuously monitored,2 and long-term outcomes demonstrate further attrition over time.3

The presence of modifiable risk factors "correlates with a more advanced atrial substrate, potentially driving higher AF recurrence in patients with greater risk factor burden at ablation,"4 the authors wrote. They noted that unrecognized or undertreated risk factors likely promote atrial remodeling even after initially successful ablation, leading to recurrence.1

Although observational studies suggest aggressive lifestyle modification reduces recurrence risk, randomized trial evidence is limited. Led by Prashanthan Sanders, MBBS, PhD, director of the Centre for Heart Rhythm Disorders at Adelaide Medical School, the investigators hypothesized that comprehensive LRFM could improve ablation outcomes by targeting the underlying substrate driving AF progression.1

The ARREST-AF Trial

For the open-label, multicenter trial conducted at 3 Australian sites, Sanders et al enrolled consecutive patients with nonpermanent symptomatic AF undergoing de novo catheter ablation between July 2014 and September 2017. Eligible participants had a BMI of 27 or greater plus at least one additional cardiometabolic risk factor. The study randomly assigned 62 individuals to LRFM and 60 to usual care, with all patients receiving guideline-directed AF management from a team blinded to randomization.1

The LRFM group attended a physician-directed clinic every 3 months and received a comprehensive program addressing multiple risk factors. Blood pressure management included twice-daily home monitoring with aggressive pharmacologic therapy targeting values less than 130/80 mm Hg. Weight management involved structured face-to-face counseling, individualized meal planning using high-protein, low-glycemic foods, and progressive aerobic exercise targeting 210 minutes weekly. The program also addressed lipid management, glycemic control, sleep-disordered breathing, with CPAP when indicated, smoking cessation, and alcohol reduction.

The usual care group received written and verbal advice about health, nutrition, and exercise but did not attend the specialized LRFM clinic.1

Key Findings

Beyond the primary endpoint, the LRFM group demonstrated significant improvements across multiple domains.

• AF symptom severity decreased substantially more in the intervention group, with lower scores for symptom frequency (mean difference -2.8 points), duration (-2.4 points), and episode severity (-0.8 points) compared with usual care. At 12 months, 21% of LRFM patients reported complete absence of AF-related symptoms versus only 5% in the control group.
• Cardiometabolic risk factor profiles improved markedly with intervention. The LRFM group lost an average of 9 kg more body weight and 7 cm more waist circumference than controls. Systolic blood pressure decreased by an additional 10.8 mmHg in the LRFM group. Exercise capacity increased by 0.9 METs compared with usual care.
• Repeat ablation procedures were required in 16% of LRFM patients vs 27% of controls. AF burden remained very low in both groups throughout follow-up. Procedural complications occurred at similar low rates, with no serious adverse events during the 12-month follow-up period.1

Limitations, Implications

Among the study’s limitations the authors acknowledge the exclusive Australian population, limiting certainty about the intervention's feasibility in other geographic regions, healthcare systems, or more diverse populations. The study addressed all LRFM components at once, so individual risk factor effects remain unclear. Further the study was powered for 12-month arrhythmia freedom, so cannot assess cardiovascular outcomes. All ablations used radiofrequency energy, leaving applicability to newer methods, like pulsed field ablation, uncertain.1

These findings demonstrate that addressing the lifestyle and risk factor drivers of progressive atrial remodeling is critical to achieving optimal long-term sinus rhythm maintenance after catheter ablation, Sanders and colleagues wrote. The magnitude of benefit achieved—a 9 kg average weight loss and substantial improvements in blood pressure control—exceeded that seen in prior single-intervention trials, underscoring the importance of comprehensive risk factor management for patients with AF undergoing ablation procedures.1

References

1. 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
2. Andrade JG, Champagne J, Dubuc M, et al, for the CIRCA-DOSE Study Investigators. Cryoballoon or radiofrequency ablation for atrial fibrillation assessed by continuous monitoring: a randomized clinical trial. Circulation. 2019;140(22):1779-1788. doi:10.1161/CIRCULATIONAHA.119.042622
3. Ganesan AN, Shipp NJ, Brooks AG, et al. Long-term outcomes of catheter ablation of atrial fibrillation: a systematic review and meta-analysis. J Am Heart Assoc. 2013;2(2):e004549. doi:10.1161/JAHA.112.004549
4. Wong CX, Sullivan T, Sun MT, et al. Obesity and the risk of incident, postoperative, and postablation atrial fibrillation: a meta-analysis of 626 603
   individuals in 51 studies.JACC Clin Electrophysiol. 2015;1(3):139-152. doi:10.1016/j.jacep.2015.04.004