Catheter ablation of atrial fibrillation reduces the risk of dementia and hospitalization during a very long-term follow-up

doi:10.1016/j.ijcard.2019.12.016

International Journal of Cardiology

Volume 304, 1 April 2020, Pages 75-81

https://doi.org/10.1016/j.ijcard.2019.12.016 Get rights and content

Highlights

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Catheter ablation (CA) in atrial fibrillation (AF) patients reduced the long-term risk of dementia and hospitalization.
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The risk of dementia was similar between AF patients receiving CA and those without history of AF.
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CA in AF patients has a lower risk of dementia than AF patients without CA, particularly in older patients aged >65 years.
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The dementia risk was higher in CA patients with AF hospitalization occurred ≤ 5 years than those without hospitalization.

Abstract

Background

Atrial fibrillation (AF) is associated with increased risks of dementia and hospitalization. Whether catheter ablation (CA) for AF might reduce such risks remains unclear. We aimed to investigate the effects of CA on dementia and hospitalization risks during a very long-term follow-up.

Methods

We studied a total of 787 AF patients receiving CA for AF treatment from 2003 to 2012 (AF CA group). The propensity score of this group was matched to another two cohorts: (a) AF patients without CA (AF no CA, n = 787) and (b) control patients without AF (n = 770). New onset of dementia of each subject was identified by ICD-9-CM codes, and information on hospitalization for AF was based on medical records. The Cox proportional hazards model was used to determine the hazard ratios (HRs) for events.

Results

During 9.0 ± 2.6 year's follow-up, a total of 139 dementia events and 732 AF-related hospitalizations have occurred. AF CA group has lower incidence of dementia than AF no CA group (adjusted HR: 0.44, p = 0.005). AF related hospitalizations were also lower in the AF CA group than that in AF no CA group (adjusted HR: 0.72, p < 0.05). In AF patients aged >65 years, CA reduced the risk of dementia compared to those without CA (adjusted HR: 0.46, p = 0.03).

Conclusions

In a 9-year follow-up, we found that CA had reduced the risk of dementia and hospitalization in AF patients, compared with those without CA. Such reduction in the risk of dementia was particularly clear in older AF patients (aged >65 years).

Introduction

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults, with rising incidences in the aging population [1]. AF is associated with higher risks of dementia characterized by progressive cognitive impairments with normal consciousness, regardless of the history of stroke or other shared risk factors [2]. Dementia has a 5% prevalence rate in the old population (>65 years), and the prevalence would double for every 5 years after the age of 65 [3]. The mechanisms of cognitive dysfunction and dementia associated with AF include cerebral thromboembolism, cerebral hypo-perfusion, and cerebral micro-bleeds [4]. Therefore, controlling cardiac rhythm is used to reduce the risks of dementia in AF patients [2].

In major clinical trials, pharmacological treatments aiming at rhythm control showed no beneficial effects in terms of morbidity, mortality, and dementia [5,6]. One major limitation of pharmacological approach to control rhythm in AF patients is the ineffectiveness and adverse effects associated with anti-arrhythmic drugs (AADs) [7]. To improve symptoms, exercise capacity, and quality of life, catheter ablation (CA) is a therapy in AF patients at different ages with multiple co-morbidities, while minimizing the ADD toxicities [8,9]. Although CA treatment might reduce the risk of cerebral thromboembolism and hypo-perfusion, silent cerebral infarctions (SCIs) during the CA procedure might adversely increase dementia risk [10]. Whether CA reduces the long-term dementia risks remains unclear.

In a prospective registry-based study, Bunch et al., reported that the risks of dementia and stroke are lower in AF patients undergoing CA (4212 compared with 16,848 age- and gender- matched AF patients without CA) [11]. Interestingly, AF patients receiving CA have similar long-term rates of dementia and stroke compared with patients without AF [11]. In that study, the follow-up duration is 3.1 years. But dementia is a progressive disease involving long-term cerebral degeneration, and the study of dementia is better based on longer follow-up [12]. We hypothesized that the risk of dementia is lower AF patients after CA when studied in long-term follow-up.

Section snippets

Methods

This study was approved in accordance with the Good Clinical Practice Guidelines by the Institutional Review Board (IRB Number: 201305044W and 2017-09-013BCF) of the Taipei Veterans General Hospital (TVGH). A detailed method section is included in an online supplement.

Baseline characteristics

Table 1 shows the baseline characteristics of the three groups. The three groups have similar percentage of male patients (p = 0.99) and age (p = 0.17). The prevalence of hypertension (p = 0.98), CKD (p = 0.83), and COPD (p = 0.057) were not different among the three groups. AF with CA group patients have higher prevalence of coronary artery disease (p < 0.001) and stroke/transient ischemic attack (TIA) (p < 0.001) than that in AF without CA group. Control group patients have higher prevalence

Discussion

Three major findings emerged from this study: (1) CA in AF patients reduced the risk of dementia and AF-related hospitalization compared with those without CA; (2) The risk of dementia was similar between AF patients receiving CA and those without history of AF; and (3) CA in AF patients has a lower risk of dementia than AF patients without CA, particularly clear in older patients aged >65 years.

Conclusions

CA in AF patients reduced the risk of dementia and AF-related hospitalization compared with those without CA under very long-term follow-up, and the effects on dementia were particularly clear for older patients (aged >65 years). We conclude that CA is an effective therapeutic strategy to reduce dementia and hospitalization risk in AF patients.

Sources of funding

This work was supported by Ministry of Science and Technology of Taiwan (MOST 107-2314-B-010-061-MY2, MOST 106-2314-B-010-046-MY3); Grant of Taipei Veterans General Hospital (V108C-032, C17-095); Research Foundation of Cardiovascular Medicine (107-02-036), and Szu-Yuan Research Foundation of Internal Medicine (No. 108016).

Declaration of competing interest

None for all authors.

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Cited by (27)

Association Between Catheter Ablation and Dementia Among Patients With Atrial Fibrillation: A Systematic Review and Meta-analysis
2024, Current Problems in Cardiology
Atrial fibrillation (AF) is associated with an increased risk of Dementia. However, the association between catheter ablation (CA) in patients with atrial fibrillation and the risk of dementia is not well established, with conflicting results to date. We aimed to evaluate the association between CA patients and the risk of Dementia. We performed a systematic literature search using the PubMed, Embase, Scopus, and Cochrane libraries for relevant articles from inception until 10th May 2023. Hazard ratios (HR) were pooled using a random-effect model, and a P-value of < 0.05 was considered statistically significant. A total of 5 studies with 125,649 patients (30,192 in the CA group and 95,457 in the non-CA group) were included. The mean age of patients among CA and non-CA groups was comparable (58.7 vs 58.18). The most common comorbidity among CA and non-CA groups was hypertension (18.49% vs 81.51%), respectively. Pooled analysis of primary outcome showed that CA was associated with a significant reduction in the risk of Dementia (HR, 0.63 [95% CI: 0.52-0.77], P < 0.001). Similarly, pooled analysis of secondary outcomes showed that the patients with CA had a lower risk of Alzheimer's disease (HR, 0.78 [95% CI: 0.66-0.92], P < 0.001) compared with the non-CA group. However, there was no statistically significant difference in the risk of vascular dementia (HR, 0.63 [95% CI: 0.38-1.06], P = 0.08) between both groups of patients. Our study suggested that catheter ablation reduced the risk of dementia and Alzheimer's disease compared to the nonablation group of patients.
Impact of Catheter Ablation on Cognitive Function in Atrial Fibrillation: A Randomized Control Trial
2023, JACC: Clinical Electrophysiology
Early postoperative cognitive dysfunction (POCD) has been reported following atrial fibrillation (AF) ablation. However, whether POCD is persistent long-term is unknown.
The purpose of this study was to determine if AF catheter ablation is associated with persistent cognitive dysfunction at 12-month follow-up.
This is a prospective study of 100 patients with symptomatic AF who failed at least 1 antiarrhythmic drug randomized to either ongoing medical therapy or AF catheter ablation and followed up for 12 months. Changes in cognitive performance were assessed using 6 cognitive tests administered at baseline and during follow-up (3, 6, and 12 months).
A total of 96 participants completed the study protocol. Mean age was 59 ± 12 years (32% women, 46% with persistent AF). The prevalence of new cognitive dysfunction in the ablation arm compared with the medical arm was as follows: at 3 months: 14% vs 2%; P = 0.03; at 6 months: 4% vs 2%; P = NS; and at 12 months: 0% vs 2%; P = NS. Ablation time was an independent predictor of POCD (P = 0.03). A significant improvement in cognitive scores was seen in 14% of the ablation arm patients at 12 months compared with no patients in the medical arm (P = 0.007).
POCD was observed following AF ablation. However, this was transient with complete recovery at 12-month follow-up.
Atrial fibrillation burden and cognitive function; a new horizon in the digital health era?
2023, International Journal of Cardiology
Atrial fibrillation and the risk of early-onset dementia and cognitive decline: An updated review
2023, Trends in Cardiovascular Medicine
The relationship between atrial fibrillation (AF) and dementia has been well described; however, recent data suggest that AF confers a greater risk for the development of early-onset dementia irrespective of clinical stroke. Numerous mechanisms have been hypothesized to explain cognitive decline in the setting of AF, including silent cerebral ischemia, cerebral hypoperfusion, and cerebral microvascular disease. Despite the emergence of data supporting the increased risk of early-onset dementia in patients with AF, the underlying mechanism remains unclear. Furthermore, the mechanism may be influenced by survival bias, genetic susceptibility, or early dysfunction of brain adaptation. Investigation into why this relationship exists could change how prevention and treatment are evaluated.
Comparative risk of dementia among patients with atrial fibrillation treated with catheter ablation versus anti-arrhythmic drugs
2022, American Heart Journal
Citation Excerpt :
First, there was 41% reduction in the risk of a dementia diagnosis in patients with AF treated with CA compared with AAD. This finding is consistent with prior work demonstrating a reduction in dementia associated with maintenance of sinus rhythm in general22 as well as those evaluations of CA specifically in which CA has consistently demonstrated improved suppression of AF over a strategy of AAD alone regardless of sex.17-19,23-25 In an analysis of Korean National Data, Kim et al observed a reduction in the risk of dementia of 27% (HR 0.73, 95% CI 0.58-0.93) in a propensity matched population of nearly 200,000 all-comers with AF treated with CA versus AAD.
Atrial fibrillation (AF) is associated with an increased risk of dementia. Emerging evidence suggests AF suppression is associated with reduced risk of dementia, but the optimal strategy to achieve this is unknown. We sought to compare the risk of dementia in patients with AF who underwent catheter ablation (CA) versus anti-arrhythmic drug (AAD) treatment.
Using the 2000 to 2021 Optum Clinformatics database, patients with AF who underwent CA versus AAD treatment (≥1 prescription fill for ≥2 different AADs) were identified and propensity score matched overall and within sex subgroups. A cause-specific hazard model was performed to assess dementia overall and in sex-specific subgroups. After matching, there were 19,088 patients per group. CA was associated with a 41% lower risk of dementia compared with AAD alone (1.9% vs 3.3%; hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.52-0.67, log-rank P < .0001). When examined by sex, dementia risk reduction associated with CA versus AAD use alone was observed among both males (HR 0.55, 95% CI 0.46-0.66) and females (HR 0.60, 95% CI 0.50-0.72). Though not studied as a primary outcome, patients treated with CA were also observed to have 49% lower associated risk of mortality compared with AAD only (HR 0.51 95% CI 0.46-0.55, P < .0001).
Among patients treated for AF, CA was associated with significantly lower risk of dementia and death compared with AADs only. These reductions in risk associated with CA versus AAD were seen in both males and females.
Impact of catheter ablation of atrial fibrillation on reduction of the risks of dementia and hospitalization
2020, International Journal of Cardiology

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View full text

Catheter ablation of atrial fibrillation reduces the risk of dementia and hospitalization during a very long-term follow-up

Highlights

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Baseline characteristics

Discussion

Conclusions

Sources of funding

Declaration of competing interest

Trends Cardiovasc. Med.

J. Am. Coll. Cardiol.

Can. J. Cardiol.

Int. J. Cardiol.

Clin. Ther.

Atherosclerosis

Int. J. Cardiol.

J. Am. Coll. Cardiol.

Mayo Clin. Proc.

Am. Heart J.

Am. Heart J.

J. Am. Coll. Cardiol.

Heart Rhythm.

Secular trends in incidence of atrial fibrillation in Olmsted county Minnesota, 1980 to 2000 and implications on the projection for future prevalence

Circulation

Cognitive dysfunction in atrial fibrillation

Nat. Rev. Cardiol.

Incidence of dementia and cognitive impairment, not dementia in the United States

Ann. Neurol.

A comparison of rate control and rhythm control in patients with atrial fibrillation

N. Engl. J. Med.

Antiarrhythmic drugs for maintaining sinus rhythm after cardioversion of atrial fibrillation: a systematic review of randomized controlled trials

Arch. Intern. Med.

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

Eur. Heart J.