Targeting Atrial Fibrillation in HFpEF: Comparative Effectiveness of Rhythm Control Strategies and Modulatory Effects of SGLT2 Inhibitors

<b>Background</b>: Atrial fibrillation (AF) is a common comorbidity in heart failure with preserved ejection fraction (HFpEF), yet the optimal rhythm control strategies and the emerging role of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in maintaining sinus rhythm remain unclear. <b>Methods</b>: We conducted a single-centre, retrospective study of 120 consecutive HFpEF patients with paroxysmal or persistent AF, treated by electrical cardioversion, radiofrequency ablation (RFA), or cryoablation. The primary outcome was AF recurrence, with secondary outcomes including time to recurrence and the impact of SGLT2i on AF recurrence. <b>Results</b>: Both cryoablation (HR = 0.226, 95% CI: 0.089-0.573, <i>p</i> = 0.002) and RFA (HR = 0.293, 95% CI: 0.131-0.654, <i>p</i> = 0.003) were associated with lower AF recurrence rates and longer arrhythmia-free survival compared to electrical cardioversion. SGLT2i therapy was independently associated with fewer recurrences (HR = 0.421, 95% CI: 0.266-0.786, <i>p</i> = 0.007) and a 12-week extension of AF-free time. <b>Conclusions</b>: In HFpEF with AF, prioritising catheter ablation over cardioversion and combining rhythm control with SGLT2i improves rhythm durability.