Gender-based Long-term Outcome for Atrial Fibrillation Patients post Catheter Ablation

Background Previous research indicates disparities in atrial fibrillation (AF) recurrence and complications following catheter ablation in women; however, long-term outcomes based on gender remain underexplored. Objective This study evaluated the long-term rates of AF recurrence and major adverse cardiovascular and cerebrovascular events (MACCE) following catheter ablation, investigating gender-related risk factors to inform clinical practice improvement. Methods We conducted a retrospective analysis using data from a prospectively observational registry of AF ablation procedures at our institution from 2015 to 2020. Patients were followed up for MACCE and AF recurrence. The risk factors of AF recurrence and MACCE were further explored. Results The study cohort consisted of 2,293 patients, including 1,441 males and 852 females, and had an average follow-up duration of 50.36 months. After catheter ablation, females exhibited a notably higher rate of recurrence compared to males, with a hazard ratio of 1.305 and a 95% confidence interval ranging from 1.101 to 1.547, which was statistically significant (p=0.0014). Gender differences in AF recurrence persisted regardless of early versus late intervention (both p<0.05). No significant difference in MACCE rates was observed between genders. Independent risk factors for AF recurrence included female gender, diabetes, left atrial diameter ≥40 mm. Conclusions Gender differences significantly impact the long-term outcomes of AF recurrence, but not MACCE rates post-catheter ablation. The study highlights the necessity to integrate gender considerations into AF management strategies. Gender-based Long-term Outcome for Atrial Fibrillation Patients post Catheter Ablation Mingjie Lin, PhD 1,# ; Wenqiang Han, PhD, MD 2,# ; Bing Rong, MD 2 ; Kai Zhang, PhD, MD 2 ; Tongshuai Chen, PhD, MD 2 ; Juntao Wang, MD 2,3 ; Yihan Li, MS 2 ; Changli Chen, MD 2 ; Lin Wu 1,** ; Jingquan Zhong, PhD, MD 2,3,* 1. Department of Cardiology, Peking University First Hospital, Beijing China 2. Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China 3. Department of Cardiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China # They made equal contributions to the study. Running title: Gender-based Outcome for Atrial Fibrillation Ablation * Corresponding author. Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China ** Corresponding author. Department of Cardiology, Peking University First Hospital, Beijing China E-mail addresses: [email protected] (L Wu); [email protected] (J.-Q. Zhong), Phone: +86 18560086597. Acknowledgments: Not applicable Abbreviations: AF - Atrial Fibrillation MACCE - Major Adverse Cardiovascular and Cerebrovascular Events TIA- Transient ischemic attacks PV-pulmonary vein LAD - Left Atrium Diameter ECG - Electrocardiography HR - Hazard Ratio CI - Confidence Interval CHA 2 DS 2 -VASc - Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke (Doubled), Vascular Disease, Age 65–74, Sex Category (Female) HAS-BLED - Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR (International Normalized Ratio), Elderly (>65), Drugs/Alcohol Concomitantly

Background Previous research indicates disparities in atrial fibrillation (AF) recurrence and complications following catheter ablation in women; however, long-term outcomes based on gender remain underexplored.

This study evaluated the long-term rates of AF recurrence and major adverse cardiovascular and cerebrovascular events (MACCE) following catheter ablation, investigating gender-related risk factors to inform clinical practice improvement.

We conducted a retrospective analysis using data from a prospectively observational registry of AF ablation procedures at our institution from 2015 to 2020. Patients were followed up for MACCE and AF recurrence. The risk factors of AF recurrence and MACCE were further explored.

The study cohort consisted of 2,293 patients, including 1,441 males and 852 females, and had an average follow-up duration of 50.36 months. After catheter ablation, females exhibited a notably higher rate of recurrence compared to males, with a hazard ratio of 1.305 and a 95% confidence interval ranging from 1.101 to 1.547, which was statistically significant (p=0.0014). Gender differences in AF recurrence persisted regardless of early versus late intervention (both p<0.05). No significant difference in MACCE rates was observed between genders. Independent risk factors for AF recurrence included female gender, diabetes, left atrial diameter ≥40 mm.

Gender differences significantly impact the long-term outcomes of AF recurrence, but not MACCE rates post-catheter ablation. The study highlights the necessity to integrate gender considerations into AF management strategies.

Atrial fibrillation; catheter ablation; gender difference; major adverse cardiac and cerebrovascular events; early intervention.

The worldwide prevalence of atrial fibrillation (AF) is estimated to be around 60 million cases, resulting in over 8 million disability-adjusted life years 1 . Differences based on sex are acknowledged in the epidemiology, pathophysiology, and clinical manifestation of AF 2-4 . Research suggests that in the case of AF, women tend to report symptoms more frequently than men and are more likely to seek medical attention for these issues. Furthermore, AF in women is linked to more severe symptoms and a diminished quality of life, as well as a heightened risk of serious complications, including stroke and mortality, when compared to men 3 . Specifically, women with AF who are on warfarin therapy face a greater risk of stroke. Additionally, women generally seem to suffer more complications and adverse reactions from antiarrhythmic medications than their male counterparts 2,5 . Catheter ablation has been shown to significantly diminish the recurrence of AF and enhance the quality of life in individuals experiencing symptomatic AF, outperforming antiarrhythmic medication therapy in effectiveness 6,7 . Women appear to be referred for catheter ablation less frequently and at later stages compared to men 8 . Research, including a meta-analysis, has indicated that when women undergo catheter ablation for AF, they may experience lower success rates coupled with a higher likelihood of stroke/transient ischemic attack (TIA) and significant complications than their male counterparts 9 . Numerous studies have identified pronounced gender differences in the outcomes of catheter ablation, often noting that women are generally older, possess a greater array of comorbid conditions, and are monitored for shorter durations post-procedure—many studies only document outcomes for one year—which could potentially distort the finding 10-13 . While gender itself is a non-modifiable factor and does influence the occurrence and progression of AF, gender disparities in long-term outcomes following catheter ablation have implications for both treatment choices and the approaches healthcare providers take to aftercare and management 1,14 . Considering these issues, our research sought to assess the long-term rates of AF recurrence and subsequent cardiovascular and cerebrovascular events (MACCE) in patients who had undergone catheter ablation at our center between 2015 and 2020. Furthermore, this study aimed to pinpoint gender-related risk factors with the intent of providing insights applicable to improving clinical practice.

Our study concentrated on analyzing the information collected from a prospectively observational registry of AF ablation procedures conducted at our institution, which has been documented in the Chinese Clinical Trial Registry (ChiCTR-OCH-14004674) 15 . The research received approval from the local Institutional Review Board, ensuring that all study participants provided written informed consent. The primary objective of the study was to assess two key outcomes: the recurrence rate of AF and the incidence of MACCE, which include stroke, TIAs, systemic embolic events, acute myocardial infarction, advanced heart failure, and mortality. We also tracked significant bleeding episodes and instances of patient hospital readmission. Study inclusion criteria mandated that participants must have undergone an AF catheter ablation at our institution between January 2015 and December 2020. Exclusions applied to those who were: (i) below 18 years of age, (ii) monitored for less than a one-year period post-ablation, or (iii) diagnosed with mitral valvular heart disease. Baseline demographic information, physical metrics including height and weight, medical histories, alcohol use patterns, and echocardiographic data were meticulously gathered and arranged. In line with contemporary protocols, we computed the CHA 2 DS 2 -VASc and HAS-BLED scores for each participant 16 . Catheter ablation procedure Prior to the catheter ablation procedure, all patients underwent transesophageal echocardiography or cardiac computed tomography imaging within 48 hours to rule out the presence of cardiac thrombosis. The procedures were conducted by seasoned physicians. During radiofrequency ablation, a circular pulmonary vein (PV) mapping catheter—either a Lasso or Pentaray by Biosense-Webster Inc.—was utilized in conjunction with a 3D electroanatomical mapping system (NavX, St. Jude Medical Inc.; CARTO 3, Johnson and Johnson, Inc.). A 3.5 mm-tip open-irrigation deflectable catheter (manufactured by Johnson and Johnson Inc. or Coolflex by St. Jude Medical Inc.; operating at 30–45 W, 47°C) was employed for the ablations. All individuals underwent a comprehensive PV isolation, and those presenting with atrial flutter were subjected to routine creation of bidirectional isthmus block. The operators had the discretion to complement the procedure with additional ablations, if deemed necessary. These could include posterior wall isolation, roof lines, ablation at non-PV trigger sites, targeting of complex fractionated atrial electrograms, or isolation of the superior vena cava 17,18 . The endpoint of ablation therapy is to achieve both electrical entrance block and exit block. If sinus rhythm is not achieved, electrical cardioversion may be performed. For the cryoablation procedure in select patients with paroxysmal AF, either a 23-mm or 28-mm Arctic Front or Arctic Front Advance cryoablation balloon catheter from Medtronic, Inc., was inserted via a guidewire into the orifice of the PV. The choice of the balloon size was determined based on the dimensions of the PV, which were assessed using procedural imaging with contrast-enhanced radiography and computed tomography. The primary aim of the cryoablation was to achieve electrical isolation of the four main PVs; this was verified by demonstrating entrance and/or exit block. The cryoablation process involved 120 to 240-second applications (temperatures not exceeding -55°C). After a waiting period of 30 minutes, the effectiveness of the isolation was checked by employing pacing maneuvers along with a circular mapping catheter to assess for the presence of entrance and/or exit block 19 . Postprocedural management and follow-up strategy Patients underwent heart rhythm evaluations using electrocardiography (ECG) or 24-hour Holter monitoring at 1-, 3-, and 6-month intervals post-discharge. Follow-up appointments were scheduled on a biannual basis thereafter. If patients experienced symptoms suggesting cardiac issues, they were encouraged to obtain an ECG. Data on MACCE were gathered biannually, either during in-person clinic visits or through telephone check-ins. AF recurrence was defined as any episode of atrial tachyarrhythmia lasting at least 30 seconds detected after the initial three-month blanking period following the ablation procedure. Decisions on continuing oral anticoagulation therapy for patients without evidence of AF recurrence post-blanking period were made in consultation with the attending electrophysiologist. For patients with a CHA 2 DS 2 -VASc score above 2, the continuation of oral anticoagulant therapy was generally recommended. After the initial three-month observation period, cessation of antiarrhythmic drugs was usually suggested. Most prescriptions for long-term medications were provided within the first year following the ablation. Statistical analysis We assessed continuous variables for normality using the Kolmogorov-Smirnov test. These variables are expressed as mean ± standard deviation (SD). To compare continuous variables, we employed the t-test. Categorical variables are presented as frequencies and percentages and were analyzed with either the Chi-square test or Fisher’s exact test, depending on their suitability. Incidence rates of MACCE are expressed as events per 100 patient-years. The Kaplan-Meier curve illustrated the percentage of patients remaining free from AF recurrences over time, with a separate analysis by gender. We used Cox proportional hazards regression analysis to determine the risk factors for AF recurrence and MACCE, with hazard ratios (HRs) and 95% confidence intervals (CIs) presented as HR (95% CI). Additionally, logistic regression analysis identified risk factors for MACCE, adopting P < 0.10 as the inclusion significance level for the model. We considered possible confounders including age, gender, AF type, AF duration since initial diagnosis, CHA 2 DS 2 -VASc score and its components, alcohol intake, left atrial diameter (LAD) ≥40 mm, and obesity (body mass index ≥28.0). To balance the baseline clinical characteristics between genders, we performed a 1:1 propensity score matching (PSM), considering factors such as age ≥60 years, obesity, AF duration since diagnosis, hypertension, stroke, vascular disease, CHA 2 DS 2 -VASc score above 2 (including risk factors other than female), AF type, and LAD ≥40 mm. Data analysis was executed using IBM SPSS Statistics version 22.0, with a significance threshold set at p < 0.05.

This study included a total of 2293 patients undergoing catheter ablation for the first time, with 1441 males and 852 females (Figure 1). Within this group, 145 patients underwent additional catheter ablation procedures during the follow-up period. In the present cohort, the average age of the patients was 59.88 ± 10.61 years; 37.9% had persistent AF; the duration from diagnosis to ablation was 36.17 ± 39.08 months; the CHA 2 DS 2 -VASc and HAS-BLED scores were 1.88 ± 1.56 and 0.51 ± 0.66, respectively; and 46.7% of patients underwent non-PV ablation. Females were significantly higher than males in terms of age, duration from diagnosis to ablation, CHA 2 DS 2 -VASc scores, HAS-BLED scores, and the prevalence of hypertension and vascular diseases; however, they had a significantly lower proportion of persistent AF and underwent non-PV ablation procedures less frequently (Table 1). After 1:1 PSM, the variables were comparable among groups (Supplementary Table S1). Primary outcomes During the monitoring period of 50.36 ± 19.65 months, 1718 patients remained free of AF, accounting for 74.9% of the study cohort. This included 77.1% of male participants and 71.2% of female participants. Among these recurrences, persistent AF was noted in 70 patients, constituting 12.2% of the cases, with no significant difference observed across groups. The Kaplan-Meier curves reveal a statistically significant difference in AF-free survival between male and female patients (HR [95%CI] 1.305[1.101-1.547], p=0.0014) (Figure 2). This gender disparity persists in the PSM population with a similar trend and an increased HR (1.363[1.117-1.663], p=0.0020) (Supplementary Figure S1). Early catheter ablation has been proposed 6,20 . we compared AF recurrence between genders in two groups: those with a diagnosis-to-ablation time ≤ 1 year and > 1 year. As illustrated in Supplementary Figure S2, the gender-based difference in AF recurrence remained consistent regardless of whether the intervention occurred early or late (HR 1.327, 95%CI 1.017-1.732 for ≤ 1 year, and HR 1.284, 95%CI 1.029-1.601 for > 1 year). The incidence of MACCE was 1.64 per 100 patient-year for female and 1.36 per 100 patient-year for male with no statistical differences among groups (HR 1.227, 95%CI 0.877-1.716, p=0.232). The majority of MACCE were new thromboembolic events with 0.93 and 0.69 per 100 patient-year for female and male respectively (HR 1.382, 95%CI 0.876-2.180, p=0.165). Risk factors associated with AF recurrence of AF and MACCE occurrence Cox regression analysis was utilized to identify risk factors associated with AF recurrence. The variables that reached statistical significance and were included in the multivariate analysis were as follows: gender (female), AF duration, presence of diabetes, CHA 2 DS 2 -VASc score, LAD≥40 mm, use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers and obesity (all p<0.10, Table 2). In the multivariable Cox regression analysis, female gender was found to be independently associated with an increased risk of AF recurrence (p = 0.003). Additionally, diabetes and LAD≥40 mm were identified as independent predictors of AF recurrence (both p<0.05, Figure 3). In the PSM patients, both female and LAD≥40 mm persisted as independent risk factors for AF recurrence (each with p<0.05, Supplementary Table S2). Further analysis according to sex revealed that in men, the independent predictors of AF recurrence in the multivariable Cox regression analysis were the duration of AF, presence of diabetes, and LAD≥40 mm. In contrast, for women, an LAD of 40 mm or greater was the sole independent predictor (Figure 4 and Supplementary Table S3 and S4). The influences on the incidence of MACCE were scrutinized using logistic regression to identify significant contributing factors. Findings from the analysis indicated that gender did not significantly impact the likelihood of MACCE incidence. Conversely, age, hypertension, diabetes, as well as the CHA 2 DS 2 -VASc and HAS-BLED scores, were identified as independent predictors for the occurrence of MACCE (Table 3). The multivariable logistic regression analysis by sex found that age was the common risk factor for male and female, and long-term antiplatelet drugs prescription was another predictor for male, while history of diabetes and alcohol consumption for female (Supplementary Table S5 and S6).

Our study aimed to unravel the long-term outcomes of AF ablation in relation to gender differences, focusing on the recurrence of AF and the incidence of MACCE in a representative Chinese cohort. The main findings of this study include: gender differences are a significant risk factor for AF recurrence after catheter ablation in patients with AF; gender differences are also present in patients with early ablation treatment; there is no significant difference in the incidence of MACCE between men and women; the risk factors for AF recurrence and MACCE after the procedure are not the same in males and females. The findings have significant implications as they reinforce and expand our comprehension of gender disparities in clinical outcomes following catheter ablation treatment for AF. The collection of sex-specific data has expanded in areas such as myocardial infarction 21, heart failure, stroke 22, sudden cardiac death, and AF 4,5,23,24 . Women with AF who are treated with warfarin therapy may face a higher risk of stroke compared to men 3 . However, studies indicate that there is no significant gender difference in the primary outcomes when undergoing left atrial appendage occlusion 25 . Gender differences in recurrence rates following catheter ablation for AF have been observed over an extended period. The meta-analysis including 19 observational studies found the rate of freedom from AF recurrence was lower in women than men at the 2.4-year follow-up 9 . Our research revealed that throughout an extended follow-up period (50.36 ± 19.65 months), women exhibited a significantly higher rate of recurrence following catheter ablation compared to men. This finding was consistent in the population matched by PSM, and gender remained an independent predictor of recurrence in multivariate regression analysis. Some studies suggest that there is no significant difference in recurrence after catheter ablation between genders. These studies have noted that women are typically older and have smaller left atrial dimensions 11,26 . Meanwhile, Ma and colleagues, through a study utilizing a 1:1 propensity-matched cohort, reported no significant difference in arrhythmia recurrence rates between genders, with the duration of AF being the lone predictor for its recurrence 27 . Early intervention has been posited to slow the progression of AF-induced alterations in the heart’s electrical and structural integrity, vascular endothelium, and metabolic functions 28,29 . As demonstrated by Masuda et al., women show a higher prevalence of left atrial low-voltage areas which are associated with more frequent AF recurrences 30 . Consequently, it is worth investigating whether similar gender differences in prognosis exist for patients undergoing early catheter ablation. In our present study, the gender differences in AF recurrence post-catheter ablation were evident regardless of whether the intervention was early or late. When analyzing the recurrence risk factors following catheter ablation for AF in different genders, distinct factors emerge for men and women; however, LAD emerged as a common risk factor across genders. Research has also highlighted that in women, other predominant risk factors include left atrial size and AF type 26,30 . Thus, it is important to incorporate gender differences into clinical evaluations, taking a comprehensive approach to assess the AF burden and the degree of left atrial remodeling. The sex-based difference of long-term outcomes including death, stroke, acute coronary syndrome etc. were main concerns for clinicians. In the CABANA trial, the primary composite outcome (death, disabling stroke, serious bleeding, or cardiac arrest) was comparable between genders 31 . Our research also suggests that gender differences are not a statistically significant factor affecting MACCE. In the EAST-AFNET 4 study, the primary outcome showed no significant difference between the sexes 31 . Kang and colleagues conducted a study by drawing on data from the National Health Insurance Service database to identify patients who received treatment for AF within one year of their diagnosis. Their research findings indicated that a rhythm control strategy was associated with a reduced risk of primary composite outcomes when compared to rate control in both male and female patients. The study further suggests that initiating treatment at an earlier stage—specifically within six months of diagnosis—may offer enhanced effectiveness in female patients 32 . The observation that there was no significant difference in the incidence of MACCE between the genders may appear counterintuitive given the established increase in stroke risk in women with AF 22 . However, it is imperative to understand that this lack of difference might be reflecting the effectiveness of the therapeutic interventions (including catheter ablation and oral anticoagulation) which could potentially neutralize the inherent gender-related risk for MACCE seen in AF populations. While the gender-based disparities in AF care are notable—ranging from symptom burden to the effectiveness of treatment interventions—the findings of this study highlight the necessity for gender-informed management strategies for AF. This implies that healthcare providers might consider adjusting their therapeutic approach considering the greater likelihood of AF recurrence in women, despite similar rates of MACCE compared to men.

of the current study include its observational nature, potential for residual confounding despite PSM, and the fact that data were sourced from a single center, which may influence the generalizability of the findings. It is also crucial to acknowledge the dynamic nature of AF management guidelines and treatment innovations that continue to influence outcomes over time. Furthermore, the study participants received inconsistent medication regimens following their operations, exhibiting a reduced frequency of anticoagulant administration and a limited use of agents aimed at preventing atrial remodeling. These factors could introduce biases in the reported outcomes. In conclusion, our research offers valuable evidence that gender differences do influence long-term outcomes post-catheter ablation for AF—particularly regarding AF recurrence rates—with important implications for the customization of treatment plans. As we move toward a more personalized medicine approach, factoring in gender-based risk nuances might enhance clinical decision-making and, ultimately, patient outcomes.

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Arch Cardiovasc Dis. 2019;112(3):171-179. 27. Ma Y, Guo L, Liu C, Xu J, Wang Y, Yi F. Sex differences in paroxysmal atrial fibrillation catheter ablation: A difference-in-difference propensity score matched analysis. Pacing Clin Electrophysiol. 2023;46(8):969-977. 28. Jie QQ, Li G, Duan JB, et al. Remodeling of myocardial energy and metabolic homeostasis in a sheep model of persistent atrial fibrillation. Biochem Biophys Res Commun. 2019;517(1):8-14. 29. Nattel S, Guasch E, Savelieva I, et al. Early management of atrial fibrillation to prevent cardiovascular complications. Eur Heart J. 2014;35(22):1448-1456. 30. Masuda M, Matsuda Y, Uematsu H, et al. Gender Differences in Atrial Fibrosis and Cardiomyopathy Assessed by Left Atrial Low-Voltage Areas During Catheter Ablation of Atrial Fibrillation. Am J Cardiol. 2023;203:37-44. 31. Van Gelder IC, Ekrami NK, Borof K, et al. Sex Differences in Early Rhythm Control of Atrial Fibrillation in the EAST-AFNET 4 Trial. J Am Coll Cardiol. 2023;81(8):845-847. 32. Kang DS, Kim D, Jang E, et al. Sex Difference in Effectiveness of Early Rhythm- over Rate-Control in Patients with Atrial Fibrillation. J Clin Med. 2022;11(17). Figure legends Figure 1. Flowchart of study. Figure 2. Kaplan-Meier curves for cumulative survival free from atrial fibrillation recurrence among groups for overall patients. Figure 3. Multivariable cox regression results of atrial fibrillation (AF) recurrence for overall patients. LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers. Figure 4. Multivariable cox regression results of atrial fibrillation (AF) recurrence for men and women. LAD, left atrial diameter. Supplementary Figure S1. Kaplan-Meier curves for cumulative survival free from atrial fibrillation in a 1:1 propensity matching patients. Supplementary Figure S2. Kaplan-Meier curves for cumulative survival free from atrial fibrillation in patients with a diagnosis-to-ablation time ≤ 1 year or > 1 year. Table 1. Baseline and follow-up information | All patients (n=2293) | Men (n=1441) | Women (n=852) | | | Age, mean (SD) (years) | 59.88(10.61) | 58.24(10.79) | 62.64(9.69)* | | 60-64 | 450(19.6%) | 269(18.7%) | 181(21.2%) | | 65-74 | 628(27.4%) | 348(24.1%) | 280(32.9%) | | ≥75 | 175(7.6%%) | 79(5.5%) | 96(11.3%) | | Persistent AF | 870(37.9%) | 599(41.6%) | 271(31.8%)* | | AF duration (months)# | 36.17(39.08) | 34.27(38.06) | 39.40(40.57)* | | Congestive heart failure | 43(1.9%) | 27(1.9%) | 16(1.9%) | | Hypertension | 1125(49.1%) | 661(45.9%) | 464(54.5%)* | | Diabetes mellitus | 371(16.2%) | 221(15.3%) | 150(17.6%) | | Prior stroke/TIA/systemic embolism | 226(9.9%) | 139(9.6%) | 87(10.2%) | | Vascular disease | 488(21.3%) | 261(18.1%) | 227(26.6%)* | | CHA2DS2-VASc score, mean (SD) | 1.88(1.56) | 1.36(1.34) | 2.77(1.50)* | | Triglyceride glucose index | 8.56(0.56) | 8.56(0.55) | 8.57(0.57) | | HAS-BLED score, mean (SD) | 0.51(0.66) | 0.45(0.64) | 0.61(0.68)* | | Renal disease | 2(0.1%) | 2(0.1%) | 0(0%) | | Liver disease | 13(0.6%) | 7(0.5%) | 6(0.7%) | | Anemia | 13(0.6%) | 2(0.1%) | 11(1.3%)* | | Alcohol consumption | 520(22.7%) | 511(35.5%) | 9(1.1%)* | | Body mass index, kg/m 2, mean (SD) | 26.19(3.55) | 26.33(3.31) | 25.95(3.92)* | | LAD 40 -50mm | 988(43.1%) | 634(44.0%) | 354(41.5%) | | >50mm | 153(6.7%) | 108(7.5%) | 45(5.3%) | | Cryoballoon ablation | 149(6.5%) | 83(5.8%) | 66(7.7%) | | Non-PV ablation | 1070(46.7%) | 734(50.9%) | 336(39.4%)* | | Observational period prescription | ||| | Non-vitamin k oral anticoagulants | 2028(88.4%) | 1271(88.2%) | 757(88.8%) | | Warfarin | 248(10.8%) | 164(11.4%) | 84(9.9%) | | Antiplatelet drugs | 367(16.0%) | 236(16.4%) | 131(15.4%) | | ACEI/ARB | 568(24.8%) | 335(23.2%) | 233(27.3%)* | | Statins | 662(28.9%) | 395(27.4%) | 267(31.3%)* | | Follow-up duration, mean(SD) (months) | 50.36(19.65) | 50.70(19.62) | 49.78(19.69)* | | AF recurrence | 575(25.1%) | 330(22.9%) | 245(28.8%)* | | Cardiovascular rehospitalization | 351(15.3%) | 204(14.2%) | 147(17.3%)* | | Major cardiovascular and cerebrovascular events | 141(6.1%) | 83(5.8%） | 58(6.8%) | | New stroke/TIA/systemic embolism | 75(3.3%) | 42(2.9%) | 33(3.9%) | | Acute myocardial infarction | 18(0.8%) | 13(0.9%) | 5(0.6%) | | Advanced heart failure | 13(0.6%) | 3(0.2%) | 10(1.2%)* | | Major bleeding | 2(0.1%) | 1(0.1%) | 1(0.1%) | | Deaths | 48(2.1%) | 32(2.3%) | 16(1.9%) | | Long-term prescription | ||| | Oral anticoagulants | 438(19.1%) | 275(19.1%) | 163(19.1%) | | Antiarrhythmic drugs | 247(10.8) | 154(10.7%) | 93(10.9%) | | Antiplatelet drugs | 742(32.4%) | 449(31.2%) | 293(34.4%) | | ACEI/ARB | 793(34.6%) | 479(33.2%) | 314(36.9%) | | Statins | 924(40.3%) | 548(38.0%) | 376(44.1%)* | | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers; PV, pulmonary vein | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers; PV, pulmonary vein | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers; PV, pulmonary vein | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers; PV, pulmonary vein | | P<0.05, compared with men; # since first diagnosis | * P<0.05, compared with men; # since first diagnosis | * P<0.05, compared with men; # since first diagnosis | * P<0.05, compared with men; # since first diagnosis | Table 2. Univariable cox regression for atrial fibrillation recurrence (n=2293) | Variable | Univariate | Univariate | | HR(95%CI) | P-value | | | Age | 1.003(0.995-1.011) | 0.441 | | Female sex | 1.305(1.106-1.540) | 0.002 | | Persistent AF | 1.116(0.945-1.318) | 0.195 | | AF duration* | 1.002(1.000-1.004) | 0.055 | | Congestive heart failure | 1.151(0.596-2.223) | 0.676 | | Hypertension | 1.024(0.870-1.206) | 0.775 | | Diabetes mellitus | 1.507(1.234-1.841) | 0.000 | | Prior stroke/TIA /systemic embolism | 1.007(0.762-1.329) | 0.962 | | Vascular disease | 1.109(0.912-1.348) | 0.300 | | CHA2DS2-VASc score | 1.061(1.008-1.116) | 0.023 | | HAS-BLED score | 0.902(0.794-1.026) | 0.116 | | Alcohol consumption | 0.879(0.718-1.075) | 0.209 | | LAD ≥ 40 mm | 1.373(1.166-1.616) | 0.000 | | Observational period prescription | || | ACEI/ARB | 1.197(0.992-1.444) | 0.061 | | Statins | 1.081(0.885-1.320) | 0.444 | | Long-term prescription | || | ACEI/ARB | 1.122(0.947-1.330) | 0.183 | | Statins | 1.079(0.909-1.281) | 0.386 | | Obesity# | 1.186(0.994-1.416) | 0.059 | | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers. | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers. | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers. | | since first diagnosis; # BMI ≥28.0 | * since first diagnosis; # BMI ≥28.0 | Table 3. Univariable and multivariable logistic regression for major cardio- and cerebrovascular events (n=2293) | Variable | Univariate | Univariate | Multivariate | Multivariate | | HR(95%CI) | P-value | HR(95%CI) | P-value | | | Age | 1.042(1.024-1.060) | 0.000 | 1.063(1.028-1.100) | 0.000 | | Female sex | 1.195(0.845-1.690) | 0.313 | 1.574(0.852-2.908) | 0.148 | | Persistent AF | 1.193(0.845-1.684) | 0.316 | || | AF duration* | 0.999(0.995-1.004) | 0.702 | || | Congestive heart failure | 0.359(0.049-2.627) | 0.313 | || | Hypertension | 1.389(0.985-1.959) | 0.061 | 1.958(1.046-3.665) | 0.036 | | Diabetes mellitus | 1.640(1.092-2.463) | 0.017 | 2.938(1.514-5.703) | 0.001 | | Prior stroke/TIA /systemic embolism | 0.762(0.405-1.433) | 0.400 | || | Vascular disease | 1.450(0.988-2.128) | 0.057 | 1.124(0.537-2.357) | 0.756 | | CHA2DS2-VASc score | 1.168(1.056-1.293) | 0.003 | 0.494(0.323-0.754) | 0.001 | | HAS-BLED score | 1.509(1.196-1.905) | 0.001 | 1.973(1.229-3.167) | 0.005 | | Alcohol consumption | 0.797(0.518-1.227) | 0.303 | || | LAD ≥ 40 mm | 1.454(1.034-2.045) | 0.032 | 1.294(0.838-1.998) | 0.244 | | Obervational period prescription | |||| | ACEI/ARB | 1.381(0.937-2.034) | 0.103 | || | Statins | 1.608(1.055-2.451) | 0.027 | 1.387(0.887-2.171) | 0.152 | | Long-term prescription | |||| | Oral anticoagulants | 1.553(1.051-2.296) | 0.027 | 1.426(0.866-2.349) | 0.163 | | Antiplatelet drugs | 1.311(0.909-1.890) | 0.147 | || | ACEI/ARB | 1.434(1.015-2.026) | 0.041 | 1.030(0.620-1.710) | 0.910 | | Statins | 1.294(0.911-1.839) | 0.151 | || | Obesity# | 1.070(0.735-1.558) | 0.723 | || | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers. | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers. | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers. | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers. | Abbreviations: AF, atrial fibrillation; CHA2DS2-VASc, congestive heart failure, hypertension, age 75 years or older (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 years, sex category (female); HAS-BLED, hypertension, abnormal renal or liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs or alcohol concomitantly; LAD, left atrial diameter; ACEI, angiotensin converting enzyme inhibitors; ARB, Angiotensin receptor blockers. | | since first diagnosis; # BMI ≥28.0 | * since first diagnosis; # BMI ≥28.0 | Supplementary Material File (figure 3 jce.docx) - Download - 193.31 KB Information & Authors Information Version history Copyright This work is licensed under a Non Exclusive No Reuse License.

Authors Metrics & Citations Metrics Article Usage 402views 72downloads Citations Download citation Mingjie Lin, Wenqiang Han, Bing Rong, et al. Gender-based Long-term Outcome for Atrial Fibrillation Patients post Catheter Ablation. Authorea. 09 March 2024. DOI: https://doi.org/10.22541/au.170996653.30242066/v1 DOI: https://doi.org/10.22541/au.170996653.30242066/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu.