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Alcohol Consumption Reduction and Clinical Outcomes of Catheter Ablation for Atrial Fibrillation

Originally publishedhttps://doi.org/10.1161/CIRCEP.121.009770Circulation: Arrhythmia and Electrophysiology. 2021;14:e009770

Abstract

Background:

Abstinence from alcohol is effective for reduction of atrial fibrillation (AF) burden. However, effects of alcohol abstinence on clinical outcomes of catheter ablation for AF remain unknown. We sought to assess association of alcohol consumption reduction with clinical outcomes of catheter ablation for AF.

Methods:

In this multicenter prospective observational study, consecutive patients undergoing catheter ablation for AF were enrolled. All patients were requested to limit alcohol consumption to <20 g/wk after the ablation. The primary end point was AF/atrial tachycardia (AT) recurrence-free survival without antiarrhythmic drugs beyond a 3-month blanking period. Percent reduction of alcohol consumption from baseline to 1-year postablation, if freed from AF/AT for 1-year, or to AF/AT recurrence was assessed. Univariate and multivariate Cox regression analyses were performed to assess the association of the percent reduction of alcohol consumption with AF/AT recurrence-free survival as well as to determine the cutoff value for the percent reduction of alcohol consumption that yielded the largest difference in AF/AT recurrence-free survival.

Results:

Of 3474 patients enrolled in this study, analysis was performed in 1720 patients who consumed alcohol regularly before ablation (64±10 years, male 88%, paroxysmal AF 55.9%, persistent AF 31.6%, longstanding persistent AF 12.5%). Median baseline alcohol consumption was 140 g/wk (interquartile range, 70–280 g). Alcohol consumption during 1-year follow-up decreased to a median of 70 g (interquartile range, 13–162 g; P<0.0001). Multivariate Cox regression analysis demonstrated that alcohol reduction of ≥1% from baseline to 1-year follow-up (median reduction, 75% [interquartile range, 45%–100%]) was associated with lower risk of AF/AT recurrence (hazard ratio, 0.630 [95% C, 0.518–0.768], P<0.001), compared with alcohol reduction of <1% (median, 0% [interquartile range, −20% to 0%]).

Conclusions:

This study suggests that abstinence from alcohol improves clinical outcomes of catheter ablation for AF.

What Is Known?

  • Management of modifiable risk factors such as weight reduction is associated with better clinical outcome after catheter ablation of atrial fibrillation.

  • Alcohol abstinence is effective for the primary and secondary prevention of atrial fibrillation.

What the Study Adds?

  • In patients undergoing catheter ablation of atrial fibrillation and taking alcohol regularly before ablation, alcohol reduction during follow-up is associated with lower recurrence rate of atrial tachyarrhythmias.

  • The impact of alcohol abstinence on clinical outcome of catheter ablation of atrial fibrillation is greater in patients who consumed a larger amount of alcohol before the ablation.

Introduction

Atrial fibrillation (AF) is a common cardiac arrhythmia that affects quality of life, comorbidities, and mortality. Although previous studies failed to demonstrate the superiority of rhythm control therapy over rate control therapy in patients with AF,1,2 a recent study demonstrated that early rhythm control therapy had been associated with a lower risk of cardiovascular morbidity than rate control therapy.3 Given that efficacy of pharmacological therapy is limited, this has led to catheter ablation being widely performed for AF. Although pulmonary vein (PV) isolation leads to greater sinus rhythm maintenance in patients with AF, ablative therapy fails to achieve rhythm control in a certain subset of patients. Therefore, various attempts to improve clinical outcomes of AF ablation continue.

The mechanisms underlying development of AF include genetic predisposition and atrial remodeling.4 Atrial remodeling occurs not only from aging and comorbidities but also from modifiable risk factors.5 The management of modifiable risk factors is crucial for rhythm control in patients with AF.6–8 Alcohol is one such modifiable risk. Alcohol consumption is associated with development of AF in a dose-dependent manner.9–14 A recent clinical trial demonstrated that abstinence from alcohol reduced AF recurrence.15 Furthermore, alcohol consumption before the ablation was associated with a poor clinical outcome of AF ablation.16–18 However, little is known about effects of alcohol reduction on clinical outcomes of catheter ablation for AF. In the ALCOHOL-AF study (Association of Alcohol Consumption With Outcome of Catheter Ablation of Atrial Fibrillation), we sought to assess freedom from atrial tachyarrhythmia after AF ablation according to alcohol reduction during follow-up.

Methods

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Study Population

This multicenter, prospective, observational study included consecutive patients undergoing de novo catheter ablation for AF from November 2017 to June 2019 at 10 centers in Japan. Exclusion criteria were (1) prior history of catheter ablation for AF, (2) age of <20 years, (3) prior history of surgical Maze procedure, and (4) no habit of regular alcohol intake. The study protocol was approved by the institutional review board at each participating center.

Study Protocol

Patients were asked about their mean weekly alcohol consumption volumes and types of alcohol over the 3 months preceding their ablation procedure. This information was then converted to grams of alcohol consumption (baseline alcohol consumption) using a conversion chart uniform across all participating institutions (Table I in the Data Supplement). Ablation techniques used in this study were PV isolation, cavo-tricuspid isthmus ablation, left atrial linear ablation including isolation of the left atrial posterior wall, mapping-guided ablation targeting complex fractionated atrial electrograms or focal activation sites, or ablation of ganglionated plexi. Ablation devices were radiofrequency with an irrigated-tip contact force sensing catheter and a 3-dimensional navigation system, cryoballoon, hot balloon, or laser balloon system. PV isolation was mandatory for all patients, but selection of ablation device for PV isolation and ablation techniques adjunctive to PV isolation were left to the discretion of the operators. Patients were categorized into 4 groups according to alcohol consumption before the ablation as follows: 0, 1 to 19, 20 to 119, and ≥120 g/wk. These cutoffs were selected, because a previous study demonstrated that alcohol abstinence was effective in the secondary prevention of AF in patients who were consuming ≥120 g of alcohol,15 and because we allowed patients to consume alcohol of <20 g/wk after the ablation procedure in expectations of improving adherence to alcohol abstinence. The primary end point was AF/atrial tachycardia (AT) recurrence-free survival, which was defined as the time from the date of the first ablation procedure until the first recurrence of AF/AT without antiarrhythmic drugs beyond a 3-month blanking period. Patients who died or were lost to follow-up before AF/AT recurrence were censored at the date of death or the last follow-up.

Follow-Up

Class I or III antiarrhythmic drugs were allowed to be given to patients during the 3-month blanking period, and discontinuation of such antiarrhythmic drugs was encouraged within the blanking period. Patients were followed at outpatient clinics at 3- and 6-months, then every 6-months thereafter. Patients were asked about mean weekly alcohol consumption and encouraged to limit alcohol consumption to <20 g/wk. This counseling was performed verbally by a cardiologist at every follow-up visit to the outpatient clinic at all participating sites. Postablation alcohol consumption was defined as mean weekly alcohol consumption averaged over the 1-year follow-up period after the ablation, if the patient did not have recurrence of atrial tachyarrhythmia during a 1-year follow-up. If the patient had recurrence of atrial tachyarrhythmia within the 1-year follow-up, postablation alcohol consumption was defined as mean weekly alcohol consumption from the ablation procedure until the time of atrial tachyarrhythmia recurrence. The percent reduction in alcohol consumption from baseline to 1-year follow-up was defined as (baseline alcohol consumption−postablation alcohol consumption)/baseline alcohol consumption ×100 (%).

An ECG was recorded at every visit to the outpatient clinic, and 24-hour Holter monitoring was performed at 3- and 6-months and every 6-month thereafter. If patients had symptoms suggestive of atrial tachyarrhythmia, an ECG, Holter monitoring, or external loop recorder was performed additionally. Discovery of persistent or paroxysmal episodes of AF/AT >30 s after the 3-month blanking period was regarded as recurrence of atrial tachyarrhythmia.

Statistical Analysis

Continuous variables were summarized by means and SDs or medians and interquartile. Categorical variables were summarized by frequencies and percentages. The distribution of these variables between groups was compared by Student t test, Mann-Whitney U test, 1-way ANOVA, or Kruskal-Wallis test for continuous variables and χ2 test for categorical variables.

Covariates associated with recurrence of AF/AT were baseline alcohol consumption (1–19, 20–119, ≥120 g/wk),15 age (<75 years, ≥75 years), gender (male, female), body mass index (<25 kg/m2, ≥25 kg/m2), AF type (paroxysmal, persistent, longstanding persistent), presence of hypertension, presence of diabetes, presence of heart failure, left atrial diameter (<40 mm, ≥40 mm), left ventricular ejection fraction (≥50%, <50%), and ablation procedure type (PV isolation alone, additional ablation). These variables were selected based on previous literature17 and medical perspective. For all analyses, we excluded participants with information missing on the preceding covariates and postablation alcohol consumption, and those whose baseline alcohol consumption was 0 g.

The primary objective of this study was to assess the association between alcohol consumption reduction and AF/AT recurrence-free survival of catheter ablation of AF. To determine the cutoff point C of the percent reduction in alcohol consumption from baseline to follow-up, which yields the largest difference in the recurrence-free survival of AF/AT (the minimal P value), we used the selection approach proposed by Lausen and Schumacher.19 For details, see Method in the Data Supplement. The 2 alcohol consumption groups were defined based on the percent reduction in alcohol consumption from baseline to 1-year follow-up (ie, <C versus ≥C).

After determining the cutoff value C, we performed univariate and multivariate Cox regression analyses to estimate hazard ratios (HRs) and corresponding 95% CIs of AF/AT recurrence-free survival. This model included the alcohol consumption groups and the above-mentioned covariates. The Kaplan-Meier method was used to estimate the survival function of AF/AT recurrence-free survival for each alcohol consumption group, and the difference in survival curves between the 2 groups was evaluated based on the log-rank (or the generalized Wilcoxon) test. These analyses were also conducted for the 6 subgroups defined by baseline alcohol consumption (1–19, 20–119, and ≥120 g/wk) and AF type (paroxysmal, persistent, and longstanding persistent). A P≤0.05 was considered statistically significant. All statistical analyses were performed using SAS version 9.4 (SAS Institute Inc, Cary, NC).

Results

Patient Characteristics

Of 3521 patients enrolled in this study, baseline alcohol consumption was available in 3474 (98.7%) patients and median baseline alcohol consumption was 14 g/wk (interquartile range [IQR], 0–151 g). The analysis set was 1720 patients (64±10 years; male, 88%; paroxysmal AF, 55.9%; persistent AF, 31.6%; longstanding persistent AF, 12.5%) after excluding those lacking information about covariates or postablation alcohol consumption, and those who did not take alcohol at baseline. In the analysis set, 115 (6.7%), 600 (34.9%), and 1005 (58.4%) patients consumed alcohol 1 to 19, 20 to 119, and ≥120 g/wk at baseline, respectively. Type of AF was associated with baseline weekly alcohol consumption (paroxysmal AF: median, 140 g [IQR, 64.8–266.7 g], persistent AF: 160 g [84–287 g], longstanding persistent AF: 168 g [98–302.4 g], P=0.003). Median follow-up period was 420 days (IQR, 369–707 days). Demographic, clinical, and echocardiographic characteristics are presented in Table 1.

Table 1. Baseline Characteristics

Overall (n=3474)Patients excluded from analysis set (n=1754, 50.5%; nondrinkers, n=1664, 47.9%; missing data, n=90, 2.6%)% reduction of alcohol consumptionP value*
No reduction group, <1% (n=618, 17.8%)Reduction group, ≥1% (n=1102, 31.7%)
Age, y±SD66±1167±1164±1063±100.1866
Male, n (%)2519 (72.5%)1005 (57.3%)546 (88.6%)968 (87.8%)0.7550
Body mass index, kg/m2±SD24.1±3.823.9±4.124.1±3.324.5±3.50.0288
AF type
 Paroxysmal AF, n (%)2118 (61.0%)1156 (65.9%)332 (53.7%)630 (57.2%)0.3614
 Persistent AF, n (%)974 (28.0%)431 (24.6%)207 (33.5%)336 (30.5%)
 Longstanding persistent AF, n (%)382 (11.0%)167 (9.5%)79 (12.8%)136 (12.3%)
Hypertension, n (%)1831 (52.7%)914 (52.1%)343 (55.5%)574 (52.1%)0.1732
Diabetes, n (%)509 (14.7%)268 (15.3%)95 (15.4%)146 (13.6%)0.2235
Heart failure, n (%)456 (13.2%)265 (15.1%)74 (12.0%)117 (10.6%)0.3901
Prior thromboembolisms, n (%)247 (7.1%)129 (7.4%)47 (7.6%)71 (6.4%)0.3786
CHA2DS2-VASc score2 (IQR, 1–3)2 (IQR, 1–3)2 (IQR, 1–3)2 (IQR, 1–2)0.0201
Left atrial diameter, mm±SD39±938±740±1539±70.0222
Left ventricular ejection fraction, %±SD63±1063±1062±1063±100.0270

AF indicates atrial fibrillation; and IQR, interquartile range.

* P value for the hypothesis test of % reduction of alcohol consumption <1% vs ≥1%.

Ablation Outcomes

In the analysis set of the 1720 patients, PV isolation was performed using radiofrequency (972, 56.5%), cryoballoon (616, 35.8%), laser balloon (108, 6.3%), and hot balloon (24, 1.4%). Additional ablation was performed in 502 patients (29.2%). Of the 502 patients, left atrial linear ablation including left atrial posterior wall isolation and ablation of complex fractionated atrial electrograms were performed in 436 (25.3%) and 132 (7.7%) patients, respectively.

Changes in Alcohol Consumption

For the analysis set, weekly alcohol consumption significantly decreased from baseline to 1-year follow-up (median: 140 g [IQR, 70–280 g] to 70 g [13–162 g], P <0.0001). Median % reduction and absolute reduction of alcohol consumption from baseline to 1-year follow-up was 39.4% (IQR, 0%–86.7%) and 38.3 g (0–137.6 g), respectively. Both % reduction and absolute reduction of alcohol consumption were the greatest in the group whose weekly alcohol consumption was ≥120 g at baseline (P=0.0015 and P<0.0001, respectively, Figure 1).

Figure 1.

Figure 1. Box plot graphs of baseline and postablation weekly alcohol consumption grouped by baseline alcohol consumption.

Percent reduction in alcohol consumption of 1% was determined to be the cutoff value C, which yielded the minimal P value (Figure I in the Data Supplement). We defined patients with percent reduction in alcohol consumption of ≥1% as the reduction group and patients with percent reduction in alcohol consumption of <1% as the no reduction group. Although there were statistically significant differences in body mass index, CHA2DS2-VASc score, left atrial diameter, and left ventricular ejection fraction, all in the P=0.02 to 0.03 range, the difference in the mean values themselves showed that demographic, clinical, and echocardiographic characteristics were similar between the 2 alcohol consumption groups (Table 1). PV isolation alone ablation strategy was more commonly observed in the reduction group than the no reduction group (817/1102 [74.1%] versus 401/618 [64.9%], P<0.001). During follow-up beyond a 3-month blanking period, antiarrhythmic drugs were more often used in the no reduction group than in the reduction group (111/618 [18.0%] versus 72/1102 [6.5%], P<0.001).

Clinical Outcome and Alcohol Consumption

There were 1102 and 618 patients in the reduction and no reduction groups, respectively. Median percent alcohol reduction in the reduction and no reduction group was 75.0% (IQR, 45.0%–100.0%) and 0% (−20.0% to 0.0%), respectively. Table 2 shows the results of the univariate and multivariate Cox regression analyses to assess the association of the percent reduction of alcohol consumption with AF/AT recurrence-free survival. In univariate Cox regression analysis, the HR for recurrence of AF/AT in the reduction group as compared with the no reduction group was 0.619 (95% CI, 0.512–0.749; P<0.001). Multivariate Cox regression analysis also showed a statistically significant association between clinical outcome and alcohol consumption reduction groups (HR, 0.630 [95% CI, 0.518–0.768], P<0.001). AF/AT recurrence-free survival rate at 1 year was 83.1% in the reduction group, and 71.5% in the no reduction group, respectively (P<0.0001 by generalized Wilcoxon test; Figure 2). AF/AT recurrence-free rate according to alcohol consumption during follow-up is provided in Result, Table II, and Figures II and III in the Data Supplement.

Table 2. Hazard Ratios for AF/AT Recurrence After Ablation

UnivariateMultivariate
Hazard ratio95% CIP valueHazard ratio95% CIP value
Alcohol reduction ≥1%0.619(0.512–0.749)<0.0010.630(0.518–0.768)<0.001
Baseline alcohol consumption
 1–19 g11
 20–119 g0.911(0.622–1.335)0.6330.918(0.623–1.354)0.666
 ≥120 g0.883(0.611–1.276)0.5090.922(0.630–1.351)0.678
Age ≥75 y1.296(1.002–1.676)0.0491.311(1.003–1.712)0.047
Female gender0.984(0.839–1.546)0.9141.139(0.839–1.546)0.404
Body mass index ≥25 kg/m21.201(0.992–1.454)0.0601.092(0.892–1.338)0.393
AF type
 Paroxysmal11
 Persistent1.792(1.447–2.218)<0.0011.657(1.317–2.085)<0.001
 Longstanding2.645(2.056–3.402)<0.0012.490(1.894–3.274)<0.001
Hypertension1.064(0.880–1.287)0.5210.961(0.785–1.176)0.696
Diabetes1.371(1.069–1.758)0.0131.205(0.927–1.568)0.164
Heart failure1.280(0.971–1.688)0.0800.920(0.662–1.279)0.619
Left atrial diameter ≥40 mm1.588(1.311–1.923)<0.0011.138(0.912–1.420)0.253
Left ventricular ejection fraction <50%1.296(0.949–1.770)0.1041.104(0.768–1.588)0.592
Ablation procedure type
 Pulmonary vein isolation alone1.01.0
 Additional ablation1.355(1.112–1.650)0.0030.731(0.577–0.926)0.009

AF indicates atrial fibrillation; and AT, atrial tachycardia.

Figure 2.

Figure 2. Kaplan-Meier analysis of atrial fibrillation/atrial tachycardia recurrence-free survival in the analysis set. P values were determined by the generalized Wilcoxon test. Red and blue lines indicate patients who reduced alcohol consumption by ≥1% and <1%, respectively.

Clinical Outcome According to Baseline Alcohol Consumption

Association of recurrence-free survival with alcohol reduction was assessed in 115, 600, and 1005 patients with baseline alcohol consumption of 1 to 19, 20 to 119, and ≥120 g/wk, respectively. Multivariate Cox regression analysis showed that recurrence-free survival time was statistically longer in the reduction group than in the no reduction group in the subgroup of baseline weekly alcohol consumption of 1 to 19 g (HR, 0.373 [95% CI, 0.163–0.853], P=0.019) and of ≥120 g (0.555 [0.428–0.720], P<0.001), but not in that of 20 to 119 (0.792 [0.569–1.102], P=0.167). Analysis based on the Kaplan-Meier curves showed that recurrence-free survival time was statistically longer in the reduction group than in the no reduction group in all three subgroups of baseline weekly alcohol consumption (Figure 3).

Figure 3.

Figure 3. Kaplan-Meier analysis of atrial fibrillation/atrial tachycardia recurrence-free survival according to baseline alcohol consumption. Patients with baseline alcohol consumption of 1-19g (A), 20-119g (B), and ≥120 g/wk (C) in the analysis set. P values were determined by the generalized Wilcoxon test. Red and blue lines indicate patients who reduced alcohol consumption by ≥1% and <1%, respectively.

Clinical Outcome According to AF Type

In the analysis set, 962, 543, and 215 patients had paroxysmal, persistent, and longstanding persistent AF, respectively. Multivariate Cox regression analysis showed that recurrence-free survival was significantly longer in the reduction group than in the no reduction group in the paroxysmal AF patients (HR, 0.550 [95% CI, 0.404–0.748], P <0.001). The result was similar in persistent AF patients (0.647 [0.469–0.893], P=0.008). However, in longstanding persistent AF, there was no statistically significant difference in recurrence-free survival between the alcohol consumption groups (0.770 [0.494–1.199], P=0.247; Figure 4).

Figure 4.

Figure 4. Kaplan-Meier analysis of atrial fibrillation (AF)/atrial tachycardia recurrence-free survival according to type of AF. Paroxysmal (A), persistent (B), and longstandint persistent AF patients (C) in the analysis set. P values were determined by the generalized Wilcoxon test. Red and blue lines indicate patients who reduced alcohol consumption by ≥1% and <1%, respectively.

Discussion

Emerging evidence demonstrates that modifiable risk factors play a role in progression of fibrillatory substrate and that the management of such risk factors is associated with better clinical outcome.6–8 In a previous study, obese postablation patients were recommended to reduce alcohol consumption in combination with management of other risk factors, and it was demonstrated that risk factor modification which resulted in weight reduction was associated with a higher rate of freedom from AF.20 However, effects of alcohol abstinence alone on clinical outcome of AF ablation, particularly in nonobese patients, are unknown. In the present study, consecutive AF ablation patients were enrolled at each site and mean body mass index was 24 kg/m2, consistent with a typical AF ablation patient cohort in Japan. Nearly half of the patients were consuming alcohol regularly at baseline. During follow-up, no instructions were given regarding dietary restrictions or exercise training except for alcohol abstinence. We found that alcohol reduction of ≥1% after ablation was associated with a 37% lower rate of AF/AT recurrence overall. We found that the benefit of alcohol reduction was greatest in the subgroup whose baseline alcohol consumption was ≥120 g/wk, with a 44.5% lower rate of AF/AT recurrence, suggesting that heavy drinkers have even more to gain from reduction in amount of alcohol consumption. Although alcohol reduction was also associated with a better clinical outcome in the subgroup with the lowest baseline alcohol consumption of 1 to 19 g, we note that only 115 patients belonged to this subgroup.

Alcohol directly affects atrial electrophysiological properties. Alcohol induces sarcoplasmic reticulum Ca2+ mishandling,21 and decreases atrial conduction velocity and atrial effective refractory period22 leading to increased AF susceptibility. Additionally, alcohol consumption is associated with risks for AF such as elevation of blood pressure,23 worsening of sleep apnea,24 weight gain,25 and left ventricular dysfunction. All of these effects of alcohol may in turn cause atrial structural and electrical remodeling,26 leading to an increase in AF burden. Importantly, a previous study demonstrated that abstinence reduces AF burden.

Prior studies reported an association between alcohol consumption and clinical outcome of AF ablation.16–18 However, these studies did not assess changes in alcohol consumption during follow-up but only at baseline. Additionally, patients were not asked to reduce alcohol consumption in these studies. Therefore, the prior studies did not address the issue of whether alcohol abstinence after PV isolation is associated with clinical outcome. One prior study did not find any association between baseline alcohol consumption and ablation outcome.27 Their results may be explained by changes in alcohol consumption during follow-up.

From the results of our study, it seems that alcohol reduction affects AF recurrence in the short-term. Kaplan-Meier curves in Figures 2 through 4 show a difference in AF/AT recurrence-free survival immediately after the blanking period, and the 2 curves run almost parallel thereafter. Voskoboinik et al15 investigated the effects of abstinence on AF recurrence. Similar to our results, in their study, freedom from AF differed between abstinence and control at 90 days of follow-up, and then the difference was stable after 90 days. Whether there is a threshold of alcohol consumption reduction for AF/AT recurrence is also an intriguing issue. We categorized patients by a cut off of alcohol reduction of 1%, and alcohol reduction of ≥1% was associated with a better outcome. In fact, however, median alcohol reduction in the subgroup of alcohol reduction of ≥1% and <1% was 75% and 0%, respectively. Considering the fact that risk of alcohol is dose-dependent,12,13 a 1% reduction may not be enough to improve clinical outcome. Further studies are required to address this issue.

The present study included the following limitations. As is true of all observational studies, confounding factors may have affected our results. For example, patients with greater reductions in alcohol consumption may have also been pursuing a healthier lifestyle. Thus, randomized studies will be required to prove a causal relationship. The amount of alcohol consumption was self-reported by patients. Binge drinking was not taken into account. Implantable devices were not used for monitoring of cardiac rhythm. Paroxysmal episodes of AF/AT may have been underdiagnosed. Sample size was relatively small in the subgroups of baseline alcohol consumption of 1 to 19 g and of longstanding persistent AF. As discussed in the above, alcohol reduction might have affected blood pressure, severity of sleep apnea or body weight. However, these variables were not assessed. Most of patients were followed for at least 1 year after the ablation, but only a limited number of patients were followed beyond 2-year follow-up. Additionally, postablation alcohol consumption was assessed until 1-year follow-up. Therefore, effects of alcohol consumption reduction on long-term clinical outcome after catheter ablation remain unknown.

Conclusions

Alcohol reduction was associated with lower rate of AF/AT recurrence after catheter ablation of AF.

Nonstandard Abbreviations and Acronyms

AF

atrial fibrillation

ALCOHOL-AF

Association of Alcohol Consumption With Outcome of Catheter Ablation of Atrial Fibrillation

AT

atrial tachycardia

HR

hazard ratio

IQR

interquartile range

PV

pulmonary vein

Supplemental Materials

Supplemental Methods

Supplemental Results

Supplemental Tables I and II

Supplemental Figures I–III

References 28

Disclosures Dr Takahashi has received research grants from Medtronic Japan, Boston Scientific, Japan Lifeline, WIN international, Abbott and Biosense-Webster, and speaker honoraria from Abbott and Biosense-Webster. Dr Yamane has received speaker honoraria from Daiichi Sankyo Company, Ltd, Japan, Boehringer Ingelheim, Abbott Japan, Bristol-Myers Squibb, Medtronic Japan, and Japan Lifeline, and research grants from Boehringer Ingelheim. Dr Satomi has received speaker honoraria from Japan Lifeline, Abbott, Medtronic and Bayer. The other authors report no conflicts.

Footnotes

The Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCEP.121.009770.

For Sources of Funding and Disclosures, see page 554.

Correspondence to: Yoshihide Takahashi, MD, PhD, Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-ku, Tokyo, 113-8510 Japan. Email

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