Catheter Ablation for Atrial Fibrillation Following CASTLE-AF: Are Women Being Referred Less Than Men?

Atrial fibrillation (AF) and heart failure (HF) are common conditions that frequently coexist. Over the past 15 years, there has been a growing amount of evidence to support the use of AF ablation in patients with systolic HF, including an article titled “Catheter Ablation for Atrial Fibrillation with Heart Failure” by the CASTLE-AF investigators, published in the New England Journal of Medicine in February 2018. How such emerging data impacted the practice patterns of catheter ablations in patients with systolic HF was unknown, both overall and across subgroups stratified by race and sex.

At #AHA23, we presented our work from the American Heart Association’s Get With The Guidelines® AFib Registry, examining the temporal trend of AF ablations before and after the publication of the CASTLE-AF trial. We included 26,678 patients with systolic HF and AF from January 2016 to December 2022. The overall use of catheter ablation increased in the post-CASTLE-AF period by 4.2-fold, and there was a proportional increase across all race and sex groups. Older age, non-white race, and female sex were associated with lower AF ablation utilization during this time period. The increase in uptake of AF ablation utilization in the post-CASTLE-AF period was similar across all race groups but not in the sex-stratified analysis. Specifically, the rate of increase in AF ablation utilization in males was significantly higher than in females.

In summary, AF ablation use in patients with systolic HF has increased in the post-CASTLE-AF era. Non-white race and female sex were associated with decreased performance of AF ablations. In the post-CASTLE-AF period, there has been increased AF ablation utilization over time for HF patients, with a higher rate of uptake for male patients compared with female patients. With the emergence of new evidence, further investigation is needed to better understand the referral patterns for AF ablations across race and sex groups to ensure equity in the delivery of AF care among all patients with HF.