Pulmonary Vein Isolation Suppresses Atrial Remodeling and Enhances Quality of Life in HFpEF Patients With Atrial Fibrillation: A Randomized Controlled Trial

Introduction Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent, accounting for nearly half of all heart failure cases, and is often complicated by atrial fibrillation (AF), which exacerbates symptoms and worsens prognosis. AF occurs in 40%–60% of HFpEF patients, contributing to structural remodeling, diastolic dysfunction, and elevated hospitalization rates. While pharmacological therapies including SGLT2 inhibitors, ACE inhibitors/ARBs/ARNI, beta‐blockers, and mineralocorticoid receptor antagonists show broad benefits, rhythm control strategies such as radiofrequency ablation (RFA) remain underexplored in this population. Methods This randomized, prospective, single‐blinded trial enrolled 84 HFpEF patients with symptomatic AF. Participants were assigned to RFA ( n = 39) or standard medical therapy ( n = 45) and followed for 1 year. Key outcomes included changes in BNP levels, left atrial diameter (LAD), left ventricular ejection fraction (LVEF), AF recurrence, and quality of life (Minnesota Living with Heart Failure Questionnaire, MLHFQ). RFA involved pulmonary vein isolation (PVI) with irrigated catheters; patients with persistent AF also underwent posterior wall isolation (PWI). The medical group received optimized guideline‐directed medical therapy (GDMT) including SGLT2 inhibitors, ACEi/ARB/ARNI, beta‐blockers, and MRA as indicated. Results RFA significantly reduced AF recurrence ( p = 0.001) and attenuated left atrial enlargement (ΔLAD: −0.2 mm vs. +2.0 mm in the medical group, p < 0.001). While LVEF remained unchanged in both groups, RFA improved MLHFQ scores ( p < 0.001), whereas medical therapy did not ( p = 0.076). BNP levels declined in both groups ( p < 0.001) but without intergroup differences. In patients with interpretable E/A ratio measurements, diastolic function appeared to improve in the ablation group compared to medical therapy ( p < 0.001). Multivariate analysis identified PVI as an independent protective factor against AF recurrence (OR = 0.20) and a driver of MLHFQ improvement ( β = −16.28). Conclusions In HFpEF patients with AF, RFA effectively suppresses atrial remodeling, reduces AF recurrence, and enhances the quality of life without altering LVEF. These benefits highlight the importance of targeting structural and symptomatic outcomes over traditional systolic function metrics. Future studies should validate long‐term benefits on hard endpoints.