Atrial fibrillation recurrence after rhythm control: gaps in outpatient risk factor management in a single-centre retrospective cohort study

Background: Guidelines recommend systematic identification and management of modifiable risk factors (RFs) in atrial fibrillation (AF) to
reduce recurrence and improve outcomes. The effectiveness of routine, single-visit outpatient interventions remain unclear. This study evaluates
the screening, prevalence, control, and initial management of modifiable RFs in patients referred for direct current cardioversion (DCCV) or catheter
ablation (CA), and their association with AF recurrence.

Methods: In this single-centre retrospective cohort study, 325 consecutive AF patients referred for DCCV or CA over two years were analysed. Electronic records were reviewed for RF screening (hypertension, elevated body mass index, glycaemic control, sleep disordered breathing, alcohol misuse), RF control status, and documentation of RF management at their index clinic visit. AF recurrence was ascertained from follow-up documentation. AF-free survival was evaluated using Kaplan-Meier analysis and log-rank testing.

Results: Risk-factor screening was commonly undertaken, with 70% having at least four of five modifiable risk factors assessed. Overall, 89% had ≥1 risk factor identified, and 71% had at least one uncontrolled risk factor at the index outpatient visit. Among those with ≥1 uncontrolled risk factor, only 14% had documentation that all uncontrolled risk factors were actively managed at that encounter, while 70% had no documented active management. During a median follow-up of 23 months, AF recurrence occurred in 61%. AF-free survival did not differ according to whether uncontrolled risk factors were fully, partially, or not managed at the index visit (log-rank p=0.95). These findings were unchanged after adjustment for age, sex, procedure type, and AF phenotype.

Conclusions: These findings highlight both the limited impact of isolated clinic encounters and the low rate of active risk-factor management in routine practice, supporting the need for more systematic and sustained approaches to risk-factor modification.