What is the clinical evidence from this study?

Study design: Cohort. Population: Persistent atrial fibrillation (n=166). Intervention: ANP/BNP ratio ≤0.7 vs. ANP/BNP ratio >0.7. Primary outcome: Atrial arrhythmia recurrence (HR 1.85, 95% CI 1.09-3.14, p=0.025).

What does this research mean for the field?

A low plasma atrial natriuretic peptide (ANP) to B-type natriuretic peptide (BNP) ratio (≤0.7) predicts higher atrial arrhythmia recurrence after catheter ablation. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

To investigate the role of atrial natriuretic peptide levels as a marker for advanced atrial fibrillation and its implications for recurrence after catheter ablation.

March 9, 2026Open Access

Impaired Atrial Natriuretic Peptide Secretion as a Marker of Advanced Atrial Fibrillation

Key Result

An ANP/BNP ratio ≤0.7 was associated with an 85% increased risk of atrial arrhythmia recurrence following initial catheter ablation for persistent atrial fibrillation (HR 1.85).

Key Points

To investigate the role of atrial natriuretic peptide levels as a marker for advanced atrial fibrillation and its implications for recurrence after catheter ablation.
Assessment of atrial natriuretic peptide and B-type natriuretic peptide levels preoperatively.
Identification of low-voltage zones in patients with atrial fibrillation.
Evaluation of atrial arrhythmia recurrence post-catheter ablation.
Low plasma ANP levels correlate with advanced atrial fibrillation stages.
Patients with low ANP showed higher recurrence rates of atrial arrhythmia after treatment.
Impaired ANP secretion may reflect atrial remodeling and associated low-voltage zones.

Study Design

Type

Cohort (n=166)

Multicenter

Structured PICO

Does a preprocedural ANP/BNP ratio ≤0.7 predict left atrial low-voltage zones and atrial arrhythmia recurrence in patients undergoing catheter ablation for persistent atrial fibrillation?

Population

166 patients with persistent atrial fibrillation undergoing initial catheter ablation, followed for a median of 583 days.

Exposure

Preprocedural serum ANP/BNP ratio ≤0.7 (defined as atrial fatigue) prior to catheter ablation

Comparator

Preprocedural serum ANP/BNP ratio >0.7 (control group) prior to catheter ablation

Outcome

Diagnostic performance of ANP/BNP ratio for predicting left atrial low-voltage zone (LVZ) presence and any atrial arrhythmia (AA) recurrences within 3 years after catheter ablation lasting ≥30 s beyond the 90-day blanking periodsurrogate

A preprocedural ANP/BNP ratio ≤0.7 serves as a useful biomarker to predict advanced atrial remodeling (LVZs) and a higher risk of atrial arrhythmia recurrence after catheter ablation in patients with persistent AF.

Main Result

Hazard Ratio: 1.85 (95% CI 1.09–3.14)

Absolute Event Rate: 47% vs 29%

p-value: p=0.025

Limitations

Single-center retrospective study with a small sample size
Different multipolar catheters were used to obtain left atrial high-density bipolar voltage maps
Radiofrequency energy was used; results may differ with other energy sources like pulsed-field ablation
ANP/BNP ratio can be influenced by several factors such as obesity, left ventricular hypertrophy, or pulmonary hypertension
Included only patients with persistent AF, limiting generalizability to paroxysmal AF

Abstract

Background: Significant atrial low-voltage zones (LVZs), indicative of advanced atrial fibrillation (AF), are associated with atrial arrhythmia (AA) recurrence following catheter ablation. Although preoperative prediction remains challenging, a low plasma atrial natriuretic peptide (ANP) level relative to B-type natriuretic peptide (BNP) reflects atrial fatigue with impaired ANP secretion and may indicate advanced atrial remodeling and LVZs.

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