Withdrawing guideline-directed medical therapy after left ventricular ejection fraction recovery following atrial fibrillation ablation: a multicentre cohort study

Journal article

Background: Atrial fibrillation (AF)-induced cardiomyopathy (AIC) is characterised by reversible left ventricular (LV) dysfunction after restoration of sinus rhythm (SR). The need for continued guideline-directed medical therapy (GDMT) for heart failure after LV ejection fraction (LVEF) recovery in AIC after catheter ablation (CA) is unclear. Methods: This multicentre cohort study across 12 UK centres included adults undergoing index AF ablation (June 2019–June 2024) with LVEF <50% preablation and recovery to ≥50% at three timepoints: preablation; early postablation (≥4 weeks) and late postablation (≥3 months or ≥3 months post-GDMT withdrawal). Patients were stratified post recovery of LVEF after CA. The primary outcome was mean LVEF at late follow-up; secondary outcomes included absolute change in LVEF, LV end-diastolic diameter (LVEDD) and SR maintenance. Results: 88 patients met inclusion enrolment criteria (61.7±10.6 years old; 91% male), of which 50 (56.8%) continued full-dose GDMT and 38 (43.2%) withdrew ≥50% of GDMT. In the GDMT-withdrawn group, mean GDMT classes decreased from 2.97±0.88 to 1.03±0.79 (p<0.001). At late follow-up, mean LVEF was comparable (56.3%±3.8% GDMT-continued vs 56.8%±5.5% GDMT-withdrawn; p=0.59), as was LVEF change (1.2% vs 0.4%; p=0.48). One relapse occurred in each group secondary to an acute coronary syndrome (2.0% vs 2.6%; p=1). LVEDD remained stable (p>0.8). SR was maintained in 82.0% vs 92.1% of patients; p=0.17. Conclusions: Selective GDMT withdrawal after sustained LVEF recovery and rhythm control did not compromise LV systolic function, remodelling or rhythm maintenance. This supports the study of personalised de-escalation strategies in AIC in prospective trials.

Authors: Al-Aidarous, S; Rajappan, S; Ahluwalia, N; Uy, CP; Abdelgawad, H

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: BMJ Publishing Group
• Journal: Open Heart
• Volume: 12
• Issue: 2
• Article number: openhrt-2025-003733
• Publication date: 2025-10-09
• Acceptance date: 2025-09-24
• DOI: 10.1136/openhrt-2025-003733
• EISSN: 2053-3624
• ISSN: 2053-3624
• Language: English
• Keywords: Heart Failure, Systolic; HEART FAILURE; Cardiac Catheterization; Atrial Fibrillation