Education & Resources
Professional and patient resources on the intersection of atrial fibrillation and heart failure.
Professional and patient resources on the intersection of atrial fibrillation and heart failure.
Understanding the epidemiology, pathophysiology, and current evidence at the intersection of atrial fibrillation and heart failure with preserved ejection fraction.
Approximately 30–40% of heart failure patients have HFpEF, and roughly 30% of these patients develop atrial fibrillation. The combined prevalence of AF in HFpEF is estimated at approximately 1.2 million patients in the United States alone—a population that continues to grow as the population ages.
AF and HFpEF share common pathophysiological pathways including atrial myopathy, systemic inflammation, and myocardial fibrosis. Each condition worsens the other in a vicious cycle: AF impairs atrial contractility and raises filling pressures, while HFpEF promotes atrial remodeling that sustains AF.
The ACC/AHA 2023 guidelines assign a Class IIa recommendation for catheter ablation to improve symptoms and quality of life. The ESC 2024 guidelines offer no specific recommendation for ablation in HFpEF. This guideline divergence reflects genuine clinical equipoise—exactly the uncertainty that CABANA-HF is designed to resolve.
The CABANA trial subgroup analysis (n=778 patients with heart failure) demonstrated a 36% reduction in the primary composite endpoint and a 43% reduction in mortality with catheter ablation. CASTLE-AF established benefit in HFrEF. However, no dedicated randomized controlled trial has ever tested ablation specifically in HFpEF—until CABANA-HF.
Patients with coexisting AF and HFpEF experience disproportionate symptom burden—exertional dyspnea, fatigue, and exercise intolerance—that exceeds either condition alone. AF-driven loss of atrial kick and irregular ventricular filling compound the diastolic dysfunction of HFpEF, making symptom relief a critical therapeutic target alongside hard clinical endpoints.
Despite advances in both AF ablation technology and HFpEF pharmacotherapy, no randomized trial has combined these strategies in a single population. Rate and rhythm control medications have limited efficacy and significant side effects in HFpEF. There is an urgent need for evidence-based guidance on whether catheter ablation can improve outcomes in this large, underserved patient population.
The treatment landscape for HFpEF has been transformed by a new generation of guideline-directed medical therapies. SGLT2 inhibitors (empagliflozin, dapagliflozin) have demonstrated clear benefit in HFpEF. Mineralocorticoid receptor antagonists (MRAs), angiotensin receptor-neprilysin inhibitors (ARNIs), and GLP-1 receptor agonists have expanded the therapeutic arsenal.
Crucially, none of these modern therapies have been tested in combination with a catheter ablation strategy for AF. Prior ablation trials in heart failure were conducted before these agents became standard of care.
CABANA-HF evaluates catheter ablation on a foundation of contemporary, optimized guideline-directed medical therapy for HFpEF. This design ensures that any observed benefit of ablation is additive to the best available medical treatment.
Pulmonary vein isolation (PVI) remains the cornerstone of catheter ablation for atrial fibrillation. The technology used to achieve PVI has evolved significantly over the past two decades.
CABANA-HF embraces PFA as the preferred modality while permitting all contemporary ablation technologies, reflecting real-world clinical practice.
CABANA-HF publications and presentations will be shared here as they become available. Target presentation venues include the Heart Rhythm Society (HRS), American Heart Association (AHA), American College of Cardiology (ACC), European Heart Rhythm Association (EHRA), and European Society of Cardiology (ESC) scientific sessions. The primary manuscript publication target is JAMA or the New England Journal of Medicine.
In accordance with NHLBI data sharing policies, de-identified CABANA-HF trial data will be made available through the Biologic Specimen and Data Repository Information Coordinating Center (BioLINCC) for qualified researchers. Data sharing is planned for November 2033, approximately two years following primary results publication.
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