A large prospective clinical practice registry found a graded association between a longer interval from atrial fibrillation diagnosis to ablation and atrial arrhythmia recurrence within 1 year.
Longer diagnosis-to-ablation time (DAT) was associated with a higher risk of atrial arrhythmia recurrence following de novo radiofrequency catheter ablation (RFA) for atrial fibrillation (AF), according to a prospective, multicenter cohort study published in JAMA Network Open.1
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Why does this matter?
Interest in the timing of rhythm-control interventions has grown since the EAST-AFNET 4 trial found that an early rhythm-control strategy, initiated within 1 year of AF diagnosis, reduced the risk of adverse cardiovascular outcomes compared with usual care.2 However, that trial assessed rhythm control using antiarrhythmic drugs or ablation and did not specifically investigate the timing of catheter ablation.
In clinical practice, ablation may be delayed by treatment with antiarrhythmic drugs, referral pathways, waiting times or delayed recognition of AF. Whether a longer interval before ablation is independently associated with poorer rhythm-control outcomes has remained uncertain.
What did the study investigate?
Researchers analyzed data from the prospective REAL-AF clinical practice registry, conducted across the United States and Canada. The analysis included 3724 adults with symptomatic paroxysmal or persistent AF who underwent de novo RFA between January 2018 and June 2023.
The mean age was 67.0 years, 40.1% of participants were female and 64.8% underwent ablation for paroxysmal AF. Median DAT was 1 year.
Patients were grouped according to a DAT of less than 1 year, 1–4 years or 5 years or longer. The primary outcome was documented AF, atrial flutter or atrial tachycardia lasting at least 30 seconds after a 90-day post-ablation blanking period.
Follow-up included ECG and ambulatory rhythm monitoring, although monitoring methods were not standardized across participating sites.
What do the data show?
During follow-up, 610 patients (16.4%) experienced atrial arrhythmia recurrence. Recurrence rates increased with longer DAT:
- 12.3% among patients with a DAT of less than 1 year;
- 16.4% among those with a DAT of 1–4 years;
- 21.8% among those with a DAT of 5 years or longer.
The fully adjusted analysis included 2052 patients with complete data. Compared with ablation within 1 year of diagnosis, a DAT of 1–4 years was associated with a 48% higher recurrence risk (hazard ratio [HR], 1.48; 95% CI, 1.08–2.01; p=0.01). A DAT of 5 years or longer was associated with a 110% higher risk (HR, 2.10; 95% CI, 1.46–3.02; p<0.001).
The association between a DAT of 5 years or longer and recurrence remained significant in separate analyses of patients with paroxysmal and persistent AF. Sensitivity analyses excluding variables with substantial missing data produced consistent findings.
Why is this relevant for cardiologists?
The findings suggest that DAT may help identify patients at increased risk of recurrent arrhythmia after ablation. However, the observational study cannot establish that treatment delays caused recurrence or that earlier ablation would necessarily improve outcomes.
DAT was based on the earliest documented AF diagnosis and may not reflect the true onset of disease. Rhythm monitoring was also not standardized, and missing left ventricular ejection fraction and atrial scar data reduced the number of patients included in the primary adjusted analysis.
The REAL-AF Registry received financial support from Biosense Webster, part of Johnson & Johnson MedTech, which participated in the registry design and reviewed the manuscript before submission.
Clinical takeaway
A longer interval between AF diagnosis and RFA was associated with a graded increase in atrial arrhythmia recurrence. Prospective randomized studies are needed to determine whether reducing the time to ablation directly improves rhythm-control outcomes.
References
- Singleton MJ, Thorne C, Dai C, et al. Diagnosis-to-ablation time and atrial arrhythmia recurrence after ablation. JAMA Netw Open. 2026;9(7):e2623171.
- Kirchhof P, Camm AJ, Goette A, et al. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med. 2020;383(14):1305–1316.
Cite: Longer diagnosis-to-ablation time linked to higher arrhythmia recurrence after AF ablation. touchCARDIO. July 15, 2026.
Disclosure: This content has been developed independently by Touch Medical Media for touchCARDIO, utilizing AI as an editorial tool (Claude (Sonnet 5) [Large language model] https://claude.ai). No funding was received in the publication of this article.
Editor: Nicola Cartridge, Director of Content
