Low-density lipoprotein cholesterol is inversely associated with left atrial low-voltage areas in patients with persistent atrial fibrillation: a retrospective cohort study

Left atrial low-voltage areas (LVAs) reflect advanced atrial remodeling and are associated with postablation recurrence in patients with persistent atrial fibrillation (PerAF). However, the relationship between routinely measured metabolic parameters and LVAs remains insufficiently characterized. This study aimed to identify clinical factors associated with LVAs in patients with PerAF, with particular emphasis on metabolic parameters. This retrospective single-center cohort included consecutive PerAF patients who underwent initial catheter ablation between January 2021 and August 2024. LVA status was analyzed as a binary outcome based on the results of the intraprocedural substrate assessment. Logistic regression was used to assess associations with LVAs, while mediation, restricted cubic spline, and quartile-based analyses were conducted as secondary analyses; the quartile-based analyses were descriptive. Postablation recurrence was assessed by Kaplan–Meier and Cox analyses. Among 404 patients, 232 (57.4%) had LVAs. Age, female sex, fibrillatory wave amplitude, left atrial diameter (LAD), and LDL-C levels were associated with the presence of LVAs. Higher LDL-C levels were associated with lower odds of LVAs (odds ratio [OR] 0.72 per mmol/L, 95% confidence interval [CI] 0.53–0.97). LAD may partly account for this association (15%–18%). Quartile-based analyses revealed heterogeneity in LVA prevalence and recurrence across LDL-C categories, but these results were descriptive. In patients with PerAF, higher LDL-C levels were independently associated with a lower likelihood of LVAs. Lower LDL-C levels may help identify patients with a higher likelihood of advanced atrial remodeling before ablation. Abbreviations: AF, atrial fibrillation; LAD, left atrial diameter; LDL-C, low-density lipoprotein cholesterol; LVA, low-voltage area; OR, odds ratio; Q1–Q4, quartiles 1–4