COAST-AF
ablating low-voltage areas on top of pulmonary vein isolation does not significantly reduce recurrence of persistent atrial fibrillation overall, but does in the half of patients who have such areas
Presented in LBS.04 at AHA 2026 (Sunday 8 November) and published simultaneously in JAMA. COAST-AF (Characterization of Arrhythmia Substrate to Ablate Persistent Atrial Fibrillation) is a single-blind randomised trial at 14 Canadian ablation centres (August 2018 to September 2024, follow-up to April 2026). 508 adults with persistent AF of more than 3 months were randomised to pulmonary vein isolation plus low-voltage area (LVA) ablation (253) or PVI alone (255); mean age 65.2, 76 percent men, 54 percent had LVA on mapping. Primary endpoint: atrial arrhythmia recurrence beyond 90 days after a single procedure. After a mean 21 months: 49.4 versus 57.5 percent, HR 0.82 (95 percent CI 0.65 to 1.04), P = 0.11. In the prespecified subgroup with LVA (268 patients): 49.3 versus 69.2 percent, HR 0.77 (0.66 to 0.91), P = 0.002; without LVA 49.6 versus 45.1 percent, HR 1.09 (0.90 to 1.32). Procedure and ablation times were longer with LVA ablation; safety was similar.
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