Differential Recurrence Risk in Paroxysmal Versus Persistent Atrial Fibrillation Post-Catheter Ablation: HFpEF as an Independent Predictor

Background: Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have bidirectional pathophysiological interactions. Although HFpEF has been associated with arrhythmia recurrence after radiofrequency catheter ablation (RFCA), whether its impact differs across AF subtypes remains incompletely understood. Objective: This study aims to evaluate the prognostic impact of HFpEF on AF recurrence following RFCA in paroxysmal versus persistent AF. Methods: A total of 509 patients who underwent RFCA for AF were enrolled in our retrospective study. These patients were categorized into two groups: the normal group and the HFpEF group. The primary endpoint was freedom from atrial tachyarrhythmias (≥30 s) after the initial 3-month blanking period post-index ablation, without any antiarrhythmic drugs. Results: HFpEF was present in 15.9% of the cohort. At the 12-month follow-up visit, sinus rhythm maintenance was recorded in 62.7% of the patients in the HFpEF group versus 82.0% in the normal group (p < 0.001). A multivariable analysis identified HFpEF as an independent predictor of AF recurrence (hazard ratio [HR]: 2.06, 95% confidence interval [CI]: 1.26–3.38, p = 0.004). After 1:1 propensity score matching, HFpEF remained an independent predictor of AF recurrence (HR 1.93, 95% CI: 1.06–3.50, p = 0.03). A subgroup analysis showed a robust association in paroxysmal AF (HR = 6.00, 95% CI: 3.07–11.73, p < 0.001) but not in persistent AF (HR = 1.43, 95%CI: 0.80–2.55, p = 0.231), with a significant interaction (p for interaction = 0.022). During the 12-month follow-up visit, an improvement in the New York Heart Association (NYHA) classification could be seen in 82.7% of the cohort, with all Class III patients showing a functional improvement. Conclusions: There is an increased risk of recurrence in patients with HFpEF post-ablation, particularly among patients with paroxysmal AF. Notably, catheter ablation remains effective at improving the NYHA functional class, even in HFpEF patients. These findings support the utilization of HFpEF as a key indicator for pre-procedural risk stratification.