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Are women with AF being under-treated with ablation?

This post is an introduction to commentary I made recently over at on Medscape. Gender features in the discussion, but there are lessons for men and women with AF.


A large study from a group of Stanford researchers made three big observations on AF ablation:

  • Women, compared with men, presented for first AF ablation at an older age and with more risk factors (higher CHADSVASC score.)
  • At 30 days after the ablation, women compared with men, suffered from more complications.
  • At one year after the ablation, women compared with men, had more re-hospitalizations but fewer cardioversions and repeat AF ablation.

The first two findings confirmed results of previous studies. For whatever reason, it’s not well-understood, women who come for first ablation often have more advanced atrial disease. It’s also well established in cardiology, not only EP, that women have higher rates of complications with procedures.

The third finding was provocative. It tempts one to think women are getting cheated out of repeat ablation and cardioversions.

Here are the Stanford authors (italics mine):

“Our findings, in context, may be indicative of potential barriers to optimal or sustained rhythm-control strategies in women. . . . These data call for greater examination of barriers and facilitators to sustain rhythm-control strategies in women.”

A reader could infer two benevolent biases in these words: women are getting stiffed out of more cardioversions and AF ablation, and that’s bad because rhythm-control strategies are good.

I would propose a contrarian view. Women who undergo first AF ablation present with more associated diseases, older age, and more advanced forms of AF. They also experience more procedural complications. It’s possible, therefore, that more rhythm control (with ablation) could worsen a gender gap in outcomes.

In other words, women might do even worse with more ablation.

The reason I propose this contrarian view gets back to the guts of the AF ablation procedure. Pulmonary vein isolation, the agreed upon foundation of AF ablation, was first described as a treatment of focal atrial tachycardia coming from within the pulmonary vein muscle bundles. (A rare form of AF.) A focal treatment for a focal disease.

Now, doctors have extended the use of PVI to people with diffuse atrial disease, metabolic risk factors (obesity, high blood pressure, diabetes), and inflammation. This can be a wrong target problem.

A 2010 study from Dr. Natale’s group showed that a higher burden of structural disease in the atria may be the reason women have more non-pulmonary vein triggers. Non-PV triggers are bad because it’s very hard to find and ablate them.

Here is the take-home:

The Stanford findings allows doctors to make opposite explanations: the easy and conventional one is that women are under treated with redo ablation; the other view is that maybe women should not get more ablation after failed ablation.

The reason we could have such opposite views is our lack of understanding of the disease AF.

Recent evidence on AF suggests that AF is often the heart’s way of manifesting “tension” or disequilibrium. The tension may be too much inflammation (pericardial fat or recent infection/surgery); or maybe the tension is too much stretch (obesity, sleep apnea, hypertension, excess endurance exercise); or maybe the tension is too much neural disruption (stress, lack of sleep, alcohol). Sometimes it’s multiple combinations of these.

The AF ablation procedure can do only one thing well: isolate the pulmonary veins. This electric fence around parts of the left atria does little to treat most of the above conditions that ail the atria.

The title and link of my referenced article is here:

Less AF Ablation in Women: Gender Bias or Appropriate Care?


5 replies on “Are women with AF being under-treated with ablation?”

Excellent post as always. You’re the voice of reason. I belong to an online AF group, and some members chat about their ablations as though it were a routine blood draw. “Oh, I’m going in for my third one. The first two didn’t take, and it’s been six months…”

I don’t know what is more frightening; the AF itself, or the medical system that insists on anti-arrhythmics and/or ablation vs. a trial of lifestyle adjustments.

I read patient accounts of multiple ablations, and can’t help but wonder how that burned/frozen cardiac tissue will be behaving a decade from now? I’m a layperson, but that question occurs for me frequently.

I’ve had four runs of AF, and looking back, I can trace each one to some form of physiological disruption: illness, hormonal changes, dehydration, neural disequilibrium, and a history of excessive endurance training. While correlation isn’t causation, I can’t help but wonder.

I also can’t help but wonder if the patient forums I belong to are somehow underwrittern by either pharma companies or medical device manufacturers; any discussion of lifestyle/nutrient management is quickly shut down as “unrelated” or “off-topic” discussions.

They’re not in my book.

Thank you again for this excellent post. In an ablation-crazy world, it’s calming to hear that one voice say, “Hold your horses, folks.”

May I ask what online AF group you belong to?

Be very interested in learning more as to how to treat Afib.

I’ve found to be helpful; lots of great information on the subsets of afib, research, and general pointers. Best of all the site isn’t underwritten by pharma companies or medical device manufacturers.

I’m a cyclist and a hiker. I had flutter, which was ablated, and then I had something worse. It was diagnosed as Afib, but it wasn’t. There were two ectopic atrial tachycardias in the left atrium. In 2013 they were fixed with cryo and RF ablation. I haven’t had a single solitary issue since then. Does anyone ever track success in the general population? I realize it’s anecdotal, but in my small circle there are success stories. It seems that Dr. Josephon’s rebukes to the community ignore the absolutely life changing event that is a successful procedure. I would hate to see people denied the opportunity to take a bike ride, or climb the mountain without wondering if their heart will leave NSR that day.

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