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

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.

We retrospectively evaluated 166 consecutive patients with persistent AF who underwent initial catheter ablation using a 3-dimensional mapping system. The optimal ANP/BNP ratio cut-off for predicting LVZ presence was determined using receiver operating characteristic curve analysis. The primary outcome was AA recurrence. An ANP/BNP ratio of 0.7 was optimal for predicting LVZ presence (area under the curve 0.76; sensitivity 81%; specificity 60%). Patients with an ANP/BNP ratio ≤0.7 (n=91) had a significantly higher prevalence of LVZs (52% vs. 15%; P<0.001) and higher AA recurrence risk following initial pulmonary vein isolation (log-rank P=0.025; hazard ratio 1.85; 95% confidence interval 1.09-3.14; median follow-up period 583 days).

Serum ANP/BNP ratio is a useful surrogate biomarker for predicting advanced atrial remodeling with significant LVZs and AA recurrence following catheter ablation. ANP secretion assessment may help in candidate selection among patients with persistent AF who can benefit from catheter ablation.