Improving Outcomes for People with Atrial Fibrillation
Summary
- Miller School of Medicine cardiovascular medicine researchers have created a risk factor modification program to address obesity in atrial fibrillation patients.
- The program is part of the team’s whole-patient approach that addresses AFib and improves overall health.
- Dr. Jeffrey Goldberger and colleagues also participated in a randomized trial designed to test whether adding GLP-1 medication to the program for obese patients could improve AFib ablation outcomes.
When David Gray arrived at UHealth—University of Miami Health System’s cardiac electrophysiology clinic, his atrial fibrillation was not under control. Despite medications, the irregular rhythm kept returning, raising the concern that the next episode was just around the corner. He wanted a new plan.
Jeffrey Goldberger, M.D., cardiac electrophysiologist and professor of cardiovascular medicine at the University of Miami Miller School of Medicine, recommended a catheter ablation for Gray, but also something that has become central to the Miller School’s treatment philosophy. Based on insights from an NIH-funded clinical trial led by the team, the Liraglutide Effects on Atrial Fibrillation (LEAF) study, Dr. Goldberger prescribed a risk factor modification program combined with a GLP-1 medication to address obesity. This is based on their findings that GLP-1 medications dramatically improve AFib ablation outcomes by affecting epicardial fat around the heart.
Today, 14 months after his ablation, Gray is 45 pounds lighter with no recurrent AFib. He’s off antiarrhythmic drugs. He remains on GLP-1 medication and, as a preventative, a blood thinner.
“I knew I was overweight, but I never really felt fat,” said Gray, 72. “I’m active and exercise every day. But if you looked at my belly or the scale, it said I’m fat, so Dr. Goldberger explained that I should go on the GLP-1 medication.”
With a family history of heart disease, Gray wanted to do everything he could to offset his risk. Beyond weight loss, he saw meaningful improvements in blood pressure, cholesterol and A1C. Through the program, he meets with a Miller School nutritionist every three months. He said he can still eat a wide variety of foods but has learned to pay closer attention to his hunger and satiety cues.
“They really gave me a new lease on life,” Gray said. “You can literally turn your health around, and I’m so grateful.”
A Whole-Patient Approach
AFib affects millions of people and can increase the risk of stroke. Catheter ablation can be highly effective, but outcomes vary. As the Miller School looks to improve ablation outcomes and reduce the recurrence of AFib through its risk factor modification program and lessons learned from the LEAF study, the team is transforming the lives of patients like Gray.
“It’s not only that we got rid of his atrial fibrillation,” Dr. Goldberger said. “David is just feeling much better and is much healthier. In the old days, we would say we were focused on treating the arrhythmia. What this shows is you have to be focused on treating the whole patient, not just the arrhythmia.”
Research in 2019 out of Australia crystalized the idea that systemically addressing risk factors improves AFib outcomes, prompting the Heart Rhythm Society to change its guidelines to include risk factor modification as a part of AFib management.
Dr. Goldberger and colleagues recognized that patients tend to do better when risk factor modification is delivered through an organized, provider-led program rather than as a brief conversation during an office visit. The team set out to build a protocol that supports patients before and after ablation.
The result was a risk factor management program designed to address weight and broader cardiovascular targets like diabetes management, blood pressure control, alcohol reduction, tobacco cessation and physical activity. Nurse practitioners track progress and help patients set goals, while nutritionists provide ongoing coaching and support.
LEAF: Building on the Foundation
Next came LEAF, the randomized trial designed to test whether adding GLP-1 medication to the regimen for obese patients could improve AFib ablation outcomes.
An endocrinology colleague, Gianluca Iacobellis, M.D., Ph.D., professor of endocrinology, diabetes and metabolism at the Miller School, had pioneered research into epicardial fat and cardiac disease. Epicardial fat sits directly against the atrial muscle, with no membrane separating fat from heart tissue. That proximity allows inflammatory molecules, adipokines, to influence the atrium. When epicardial fat becomes inflamed, it creates conditions that make AFib more likely to persist or recur.
LEAF tested two strategies. One group received the risk factor modification program alone. The other received the program plus liraglutide, an early GLP-1 medication in the same drug class as semaglutide. The protocol also challenged a longstanding clinical rhythm.
“Normally, somebody comes to your office and says, ‘I want an ablation,’ and you sign them up next week,” Dr. Goldberger said.
In LEAF, the team first treated patients for three months, either with risk factor modification alone or with added liraglutide, before performing the ablation. The idea was to give the atrium time to heal, become less inflamed and be less primed to return to AFib after ablation.
The study’s results were striking.
“Adding liraglutide to risk factor modification tremendously improved outcomes after ablation,” Dr. Goldberger said.
These findings have been presented at several national meetings, and the team is working toward publication. They also are considering next steps, including a potential multicenter study and additional questions about which patient groups may benefit most.
“This is transformational cardiology: not just treating an arrhythmia, but changing the trajectory of a person’s health through evidence-based risk-factor optimization paired with advanced procedural therapy,” said Yiannis Chatzizisis, M.D., Ph.D., professor and chief of the Division of Cardiovascular Medicine at the Miller School. “We are translating rigorous, NIH-funded science into a model that measurably improves outcomes for the patients we treat every day.”
In clinical practice today, the program increasingly reflects the mindset of optimization before intervention. For some patients, this includes meeting weight targets before ablation.
“We’ll often give patients weight goals and say, ‘We’ll do your ablation when your weight hits X,’” Dr. Goldberger said.
While insurance barriers to the GLP-1 medications remain, Dr. Goldberger hopes that will soon ease.
They really gave me a new lease on life. You can literally turn your health around, and I’m so grateful.
Patient David Gray
What’s Next: Better Diagnostics, Smarter Therapeutics
The team, one of the top AFib research programs in the world, maintains a research agenda that extends well beyond risk factor management and GLP-1 medications. They are developing tools that could reshape how AFib is measured, predicted and treated, moving the field toward more individualized care.
Working with engineering colleagues at the University of Miami, the team has developed signal-processing techniques designed to better visualize AFib on testing. Historically, the ECG is interpreted by physicians to determine whether a patient has AFib or not. While the fibrillatory waves produced by the atria in patients with AFib differ from patient to patient, there is no current paradigm to evaluate these.
The challenge is that the atria produce low-voltage signals. The ventricles dominate with larger voltages. This makes it difficult to focus on the fibrillatory waves of the AFib. Their method subtracts the ventricular activity, leaving a clearer view of the atrial signals. Preliminary studies have shown the utility of analyzing the atrial fibrillatory signals.
Toward Individualized Stroke Risk
The team is studying 4D flow MRI to visualize and quantify blood flow inside the left atrium. Stroke prevention is a central concern in AFib because the atrium doesn’t contract normally so blood can pool and clot, increasing stroke risk. Anticoagulation therapy reduces the stroke risk by about 75 percent, but it also increases bleeding risk. Researchers hope the 4D flow MRI can refine risk prediction by moving beyond population-based scoring toward individual physiology.
“We’ve never before had a physiologic measure of who is at high risk,” Dr. Goldberger said. “With 4D flow MRI, we can measure blood flow and stasis, and we’re studying whether it predicts stroke risk.”
More Precise Ablation Targets
Another approach the team is studying is electrogram morphology recurrence mapping (EMR), which aims to identify the specific drivers of AFib in individual patients. While success rates for AFib that comes and goes are strong — about 70 to 80 percent — persistent AFib remains more challenging. Standard pulmonary vein isolation can be less effective in persistent cases, in part because drivers might arise from outside the pulmonary veins.
“The prevailing concept is that you have to ablate other areas to get a higher success rate,” Dr. Goldberger said. “Most of those strategies haven’t been very effective as the other areas are chosen empirically. We want to figure out for each individual patient where their AFib is coming from and target that site for ablation.”
In the team’s randomized trial, two out of three patients receive EMR-guided ablation that targets drivers if found outside the pulmonary veins and one out of three receive standard care.
The group is investigating metabolomic, proteomic and genomic factors tying AFib and epicardial fat, part of their broader effort to understand why AFib behaves differently across patients and how treatment can become more precise. They are in the final stages of analyzing data on how epicardial fat may relate to AFib differently across racial groups, with results expected in the coming months.
Tags: AFib, atrial fibrillation, cardiovascular risks, Division of Cardiovascular Medicine, Division of Endocrinology Diabetes and Metabolism, Dr. Gianluca Iacobellis, Dr. Jeffrey Goldberger, Dr. Yiannis Chatzizisis, Newsroom, technology