Identification of clinical risk factors for arrhythmia recurrence in atrail fibrillation patients undergoing catheter ablation: a systematic review and meta-analysis
K W P Chan, D S F Yu, J W K Ho, C W Y Wong, P W C LiAbstract
Background
Arrhythmia recurrence after atrial fibrillation (AF) catheter ablation remains a significant clinical challenge, shaped by complex interactions among procedural factors, arrhythmogenic substrates, comorbidities, and lifestyle. Prior meta-analyses have been limited by narrow risk factor scopes, absence of AF phenotype-specific analyses, and failure to distinguish between comorbidity presence and active management.
Purpose
This is the most comprehensive meta-analysis to date exploring a wide spectrum of clinical risk factors, including underexplored lifestyle and psychological variables, and their differential effects across AF phenotypes.
Methods
Eight databases were searched from inception to 20 December 2024 for prospective cohort studies. Thirty discrete risk factors spanning five domains were evaluated: sociodemographic (e.g. age, sex); AF-related (e.g. AF history, persistent AF); atrial substrate (left atrial size); lifestyle (e.g. alcohol consumption, smoking); and comorbidities (e.g. hypertension, diabetes). Two reviewers independently performed study selection, data extraction, and quality assessment. Multivariable-adjusted hazard ratios (aHRs) were pooled via random-effects meta-analyses, with subgroup, meta-regression, and sensitivity analyses. Heterogeneity was assessed using I2 >50% and Cochran’s Q test.
Results
A total of 120 studies comprising 36,674 AF patients undergoing radiofrequency or cryoballoon ablation were included. Beyond established risk factors (female sex, persistent AF, longer AF history, left atrial enlargement, hypertension, vascular disease, diabetes, metabolic syndrome, sleep apnoea and chronic kidney disease), novel lifestyle and non-cardiac risk factors emerged: smoking (aHR 2.36, 95%CI 1.52–3.67), alcohol consumption (aHR 1.38, 95%CI 1.12–1.69) and periodontitis (aHR 2.04, 95%CI 1.48–2.83) in main analysis (Figure 1), and psychological factors (anxiety: aOR 2.54, 95%CI 1.59–4.04; depression: aOR 2.86, 95%CI 1.51–5.41) in sensitivity analysis. Uncontrolled hypertension (aHR 1.67, 95% CI: 1.12–2.40) and untreated sleep apnoea (aHR 2.41, 95%CI 1.51–3.86) posed substantially higher risks than disease presence alone, highlighting the importance of disease management. Subgroup analyses demonstrated consistent effects across paroxysmal and persistent AF phenotypes (all p>0.05; Figure 2). Meta-regression identified female proportion, publication year and regional variations as effect modifiers. Publication bias was detected only for LA diameter.
Conclusions
This meta-analysis establishes an expanded, evidence-based pre-ablation risk profile with consistent effects across AF phenotypes. By uniquely integrating lifestyle and psychological factors alongside disease management status, these findings enable development of individualised risk prediction models and structured pre-procedural optimization programs, advancing precision medicine in AF management to improve post-ablation outcomes.