Thank you for sharing your thoughts on this study. I am confused by your conclusion: "To me, PRAGUE 25 rests in the literature as a “negative” trial for lifestyle management vs ablation. But for those of us focused on the overall health of our patients, it clearly supports a lifestyle management program before ablation." I am not clear on why you view these as mutually exclusive treatment options for patients. LFM clearly was inferior to ablation for the primary endpoint of freedom from AF. There was biological plausibility to suggest that LFM may be non inferior to ablation for this endpoint, but the well-designed study simply did not show this. There is no biological plausibility for ablation to improve metabolic endpoints, so emphasizing these as a "win" for LFM is, at best, disingenuous. AF ablation reduces AF, and substantially more effectively than LFM. But no one has ever suggested to me that AF ablation would fix metabolic syndrome.
As an aside, I hope this study follows these patients long after the resource-intensive and potentially costly LFM interventions (dietary and exercise specialists via in person, mobile apps, phone call communication) are completed. It is reasonable to doubt sustainability of these metabolic benefits long-term without continued intervention.
"But for those of us focused on the overall health of our patients, it clearly supports a lifestyle management program before ablation. For if you only ablate AF in these patients, you clearly achieve lesser health status." ie lifestyle changes improve AF and overall health.
Actually, I did read and think about the ending statement. The unproven assumption here is that modest weight loss, improved glycemic control as measured by A1C, and superior fitness as measured by VO2 Max have any effect on health or disease. Simply stating that does not constitute proof. Perhaps a control group with medication only and no lifestyle changes would demonstrate that; but that was not done.
I guess there is a lot of assumptions. How can someone study ridiculous extremes? Is anything more than modest weight loss (also not really defined) extreme?
This is such a good reminder of how "negative" trials can still tell a powerful story — if we’re willing to look past the primary endpoint.
PRAGUE 25 might not be a win for lifestyle over ablation on paper, but the fact that weight loss, glycemic control, and fitness improved without any procedural risk is striking. Especially since ablation didn’t outperform on AF burden or quality of life.
How do we get more patients — and maybe even clinicians — to recognize that a trial’s primary endpoint doesn’t always tell the whole story? And how can we nudge more people to read medical news with an eye for nuance, rather than headlines?
Curious how others are thinking about this, especially in the context of newer tools like GLP1s that might shift the equation further in favor of conservative approaches.
Unfortunately, there is no established program of lifestyle modification that has been successful in getting more than a small minority of patients to continue it long-term. Successful weight loss programs include bariatric surgery and GLP-1 drug treatments, which have to be maintained long-term. I'm not saying give up trying, but realistically, most patients have to be offered more if they are to succeed.
I find the primary endpoint to be largely clinically irrelevant for pts. For my pts who opt for non-ablative approaches, a single >30s episode of AF at 2 years would be considered a win, and cause to maintain the status quo.
I understand this was a small trial, and perhaps ILR for all participants was not feasible. But IMO and experience, total AF burden would be a much more clinically relevant (and pt QOL-relevant) primary endpoint. And their method of assessing AF burden (Q3 Mon week-long Holter in year 1, and Q6 Mon week-long Holter in year 2) is simply inadequate.
But short of that, a >30s episode that required intervention (such as an ER visit +/- cardioversion) would still be far more meaningful than simply time duration.
I do have a question about OSA. There is plenty of observational evidence suggesting correlation btw OSA and AF. What is the body of RCT evidence proving causation and benefit of intervention on OSA for improving AF endpoints? To my knowledge this is very limited.
"In patients with paroxysmal AF and OSA, treatment with CPAP did not result in a statistically significant reduction in the burden of AF."
"Our findings show that CPAP therapy, compared with usual care alone, has no effect on reducing the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation and moderate to severe sleep apnea. Moreover, treatment with CPAP had no effect on quality of life or daytime sleepiness in this group of patients. We observed that the number of serious adverse events was higher in the CPAP group (seven events) than in the control group (two events). Although some of them were unlikely to be related to CPAP, it is conceivable that some of the events can be attributed to CPAP treatment"
"Effect of Continuous Positive Airway Pressure on Arrhythmia in Atrial Fibrillation and Sleep Apnea: A Randomized Controlled Trial" American Journal of Respiratory and Critical Care Medicine
Sweet. Thanks for the heads up. That journal is not on my scan list. And Open Evidence gave me a very similar summary as you did, and provided a hyperlink to the article to boot.
No problem. I don't know anything about afib but I'm pretty knowledgeable about OSA. I think doctors should guard against screening and therapeutic nihilism for sleep apnea despite all the ambiguous and negative RCTs.
There was a big screening disparity for OSA. A third were screened in the ablation arm. A little over half in the lifestyle arm. I hope surgeons are not taking the view that OSA doesn't need to be addressed because you are getting an ablation. Keyword is "hope". If people in a formal study are being underscreened what is happening in the wild?
Who says the obese patient with diabetes and high blood pressure has "impaired quality of life"? And if the impaired quality of life is due to AF, what leads you to think that reducing obesity improves quality of life? Note that quality of life indicators are highly vulnerable to the placebo effect, and weight loss is a powerful placebo. Anecdotal evidence - I lost half my body weight, normalised my BMI, the biomarkers improved, marked improvement in weight stigma from health professionals and lay people alike - but my well-being didn't improve one iota! I subjectively didn't feel any better - but my lab tests did!!! No quality of life improvement here whatsoever - unless you count the reduction in weight stigma.
For some their mobility measurably improves, they sleep better because their sleep apnea is reduced, joint pain is reduced but for others it doesn't improve one iota.
The distortion of Medicine into the dualism of body and “everything else,” crystallized in Western medicine more than a century ago, has forced us to think about, diagnose, and treat signs and symptoms as if they were separate and independent diseases or illnesses—each approached by different (and independent) specialists. This has led us into a paradox: the very hallmark of this specialized approach is its abandonment of any integral, truly causal treatment of these so-called diseases.
What could an interventional electrophysiologist (or an endocrinologist, internist, psychiatrist, or “therapist”) meaningfully do if 86% of the conditions they treat in chronic disease today are metabolic in origin?
This is not merely rhetorical. It is a theory grounded as the foundation for a doctoral dissertation: that perhaps 90% of modern chronic disease—including many infectious diseases—or, in this case, atrial fibrillation, and the 20 characteristic signs of metabolic syndrome (including sleep apnea), are in fact the result of the prolonged, unremitting expression of the same adaptive metabolic syndrome our species developed at least 30,000 years ago to survive chronic food insecurity—when humans evolved to endure, with stoic resilience, an incomplete, imbalanced, inadequate meal only every 36 hours on average, thus securing the survival of our species.
What if atrial fibrillation, like virtually all cardiovascular diseases, cancers, and neurodegenerative disorders, is simply a terminal or distal event in this chronic metabolic syndrome—now dysregulated and anachronistic in our era of caloric abundance—whose intermediate causal substrate is persistent obesity?
If this were true, Dr. Mandrola, what would be the point of performing an ablation on a patient with uncontrolled metabolic syndrome without ever addressing the most primordial cause: what they put in their mouth?
Consider the sensationalist TV show starring bariatric surgeon Younan Nowzaradan, which frames the “magical” solution to morbid obesity in weight-loss surgery. The show does acknowledge psychological trauma and childhood sexual abuse as triggers of compulsive overeating and sends patients to therapists to control their “food anxiety.” Yet it completely overlooks that American society, for over 80 years, has been subjected to a radical transformation and artificialization of its standardized diet—one that is not only highly toxic and nutritionally inadequate but also profoundly addictive, especially regarding refined carbohydrates. This is why, as of 2023, 9 out of 10 American adults lack metabolic health.
In the face of this complex reality—an addiction to substances more than ten times as addictive as cocaine—what is the purpose of ablating a human being’s cardiac conduction system?
Perhaps, by borrowing from Dr. Nowzaradan’s model, we should instead challenge ourselves to create a structured lifestyle intervention program to improve metabolic health in atrial fibrillation patients—using realistic measures: clean water, breathing practices, regular physical activity, restorative sleep, sunlight exposure, supplementation, sexual health, intellectual engagement, and nurturing relationships with others and with the environment—and to verify progress through objective outcome markers (waist circumference, blood pressure, HbA1c, apnea indices, etc.), not merely weight or BMI. Once patients reach that threshold, if still indicated, then and only then consider rewarding them with ablation of their cardiac conduction system.
This paradox reminds us of the insight attributed to Maimonides, whose words echo across centuries:
“The physician should not treat the disease but the patient who is suffering from it.”
In other words, if we fail to address the true roots of illness, all our high-technology interventions risk becoming elaborate ways of missing the point.
I think the GLP's are going to change this dramatically. The other interesting thing about GLP is not only do you lose weight but addictive behavior seems to be reduced in many cases, and this includes the use of alcohol. It would be a fascinating comparison. You don't even have to talk about lifestyle. Just compare GLP initiation at the onset with catheter ablation specifically comparing those who successfully lost weight to the ablation arm. In town, patients were put on the partial meal replacement programs that included a weekly visit with a coach. Substantial weight loss was achieved in those that actually started at the program and what a shocker everything got better. It's still a lot harder than the GLPs. I wonder if it's not unreasonable to give people that option before you take them down the path of an ablation?
"You can ablate the AF, get paid a lot, declare victory and send the patient back to the referring doctor still with diabetes, high blood pressure and impaired quality of life."
And then still make money with repeat visits SBD blood work. A total scam
Nice review of this important trial. The takeaway for me is an all-of-the-above approach: catheter ablation for selected patients who will benefit from the procedure and LFM for everyone. I have had a few patients who chose LFM first and did not return for ablation, but it is the exception. I do tell every patient that LFM will do more for your long-term cardiovascular health than anything I can do and will reduce your risk of needing a repeat procedure. I also include alcohol reduction for habitual daily or binge drinkers.
For me, the most troubling statement in this essay is "declare victory and send the patient back to the referring doctor still with diabetes, high blood pressure and impaired quality of life." Given the statistics, it's obvious that obesity causes greater disease burden and lower quality of life. Yet the medical system is organized around highly siloed specialists independently treating different sequelae rather than attacking the underlying causes of illness in a coordinated manner.
Thank you for sharing your thoughts on this study. I am confused by your conclusion: "To me, PRAGUE 25 rests in the literature as a “negative” trial for lifestyle management vs ablation. But for those of us focused on the overall health of our patients, it clearly supports a lifestyle management program before ablation." I am not clear on why you view these as mutually exclusive treatment options for patients. LFM clearly was inferior to ablation for the primary endpoint of freedom from AF. There was biological plausibility to suggest that LFM may be non inferior to ablation for this endpoint, but the well-designed study simply did not show this. There is no biological plausibility for ablation to improve metabolic endpoints, so emphasizing these as a "win" for LFM is, at best, disingenuous. AF ablation reduces AF, and substantially more effectively than LFM. But no one has ever suggested to me that AF ablation would fix metabolic syndrome.
As an aside, I hope this study follows these patients long after the resource-intensive and potentially costly LFM interventions (dietary and exercise specialists via in person, mobile apps, phone call communication) are completed. It is reasonable to doubt sustainability of these metabolic benefits long-term without continued intervention.
Wonder if anyone is looking at GLP-1s against CA?
A major limitation was mortality was not assessed. AF is just a surrogate outcome. If they assessed mortality, things could have been different!
Further evidence that "lifestyle" factors (unless taken to ridiculous extremes) have nothing to do with health and disease.
You may have missed the end.
"But for those of us focused on the overall health of our patients, it clearly supports a lifestyle management program before ablation. For if you only ablate AF in these patients, you clearly achieve lesser health status." ie lifestyle changes improve AF and overall health.
Actually, I did read and think about the ending statement. The unproven assumption here is that modest weight loss, improved glycemic control as measured by A1C, and superior fitness as measured by VO2 Max have any effect on health or disease. Simply stating that does not constitute proof. Perhaps a control group with medication only and no lifestyle changes would demonstrate that; but that was not done.
I guess there is a lot of assumptions. How can someone study ridiculous extremes? Is anything more than modest weight loss (also not really defined) extreme?
Maybe we both see what we want to see in this.
This is such a good reminder of how "negative" trials can still tell a powerful story — if we’re willing to look past the primary endpoint.
PRAGUE 25 might not be a win for lifestyle over ablation on paper, but the fact that weight loss, glycemic control, and fitness improved without any procedural risk is striking. Especially since ablation didn’t outperform on AF burden or quality of life.
How do we get more patients — and maybe even clinicians — to recognize that a trial’s primary endpoint doesn’t always tell the whole story? And how can we nudge more people to read medical news with an eye for nuance, rather than headlines?
Curious how others are thinking about this, especially in the context of newer tools like GLP1s that might shift the equation further in favor of conservative approaches.
Unfortunately, there is no established program of lifestyle modification that has been successful in getting more than a small minority of patients to continue it long-term. Successful weight loss programs include bariatric surgery and GLP-1 drug treatments, which have to be maintained long-term. I'm not saying give up trying, but realistically, most patients have to be offered more if they are to succeed.
I find the primary endpoint to be largely clinically irrelevant for pts. For my pts who opt for non-ablative approaches, a single >30s episode of AF at 2 years would be considered a win, and cause to maintain the status quo.
I understand this was a small trial, and perhaps ILR for all participants was not feasible. But IMO and experience, total AF burden would be a much more clinically relevant (and pt QOL-relevant) primary endpoint. And their method of assessing AF burden (Q3 Mon week-long Holter in year 1, and Q6 Mon week-long Holter in year 2) is simply inadequate.
But short of that, a >30s episode that required intervention (such as an ER visit +/- cardioversion) would still be far more meaningful than simply time duration.
I do have a question about OSA. There is plenty of observational evidence suggesting correlation btw OSA and AF. What is the body of RCT evidence proving causation and benefit of intervention on OSA for improving AF endpoints? To my knowledge this is very limited.
"In patients with paroxysmal AF and OSA, treatment with CPAP did not result in a statistically significant reduction in the burden of AF."
"Our findings show that CPAP therapy, compared with usual care alone, has no effect on reducing the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation and moderate to severe sleep apnea. Moreover, treatment with CPAP had no effect on quality of life or daytime sleepiness in this group of patients. We observed that the number of serious adverse events was higher in the CPAP group (seven events) than in the control group (two events). Although some of them were unlikely to be related to CPAP, it is conceivable that some of the events can be attributed to CPAP treatment"
"Effect of Continuous Positive Airway Pressure on Arrhythmia in Atrial Fibrillation and Sleep Apnea: A Randomized Controlled Trial" American Journal of Respiratory and Critical Care Medicine
Sweet. Thanks for the heads up. That journal is not on my scan list. And Open Evidence gave me a very similar summary as you did, and provided a hyperlink to the article to boot.
No problem. I don't know anything about afib but I'm pretty knowledgeable about OSA. I think doctors should guard against screening and therapeutic nihilism for sleep apnea despite all the ambiguous and negative RCTs.
There was a big screening disparity for OSA. A third were screened in the ablation arm. A little over half in the lifestyle arm. I hope surgeons are not taking the view that OSA doesn't need to be addressed because you are getting an ablation. Keyword is "hope". If people in a formal study are being underscreened what is happening in the wild?
Data is from Supplemental Table 5.
Who says the obese patient with diabetes and high blood pressure has "impaired quality of life"? And if the impaired quality of life is due to AF, what leads you to think that reducing obesity improves quality of life? Note that quality of life indicators are highly vulnerable to the placebo effect, and weight loss is a powerful placebo. Anecdotal evidence - I lost half my body weight, normalised my BMI, the biomarkers improved, marked improvement in weight stigma from health professionals and lay people alike - but my well-being didn't improve one iota! I subjectively didn't feel any better - but my lab tests did!!! No quality of life improvement here whatsoever - unless you count the reduction in weight stigma.
For some their mobility measurably improves, they sleep better because their sleep apnea is reduced, joint pain is reduced but for others it doesn't improve one iota.
Dr. Mandrola,
The distortion of Medicine into the dualism of body and “everything else,” crystallized in Western medicine more than a century ago, has forced us to think about, diagnose, and treat signs and symptoms as if they were separate and independent diseases or illnesses—each approached by different (and independent) specialists. This has led us into a paradox: the very hallmark of this specialized approach is its abandonment of any integral, truly causal treatment of these so-called diseases.
What could an interventional electrophysiologist (or an endocrinologist, internist, psychiatrist, or “therapist”) meaningfully do if 86% of the conditions they treat in chronic disease today are metabolic in origin?
This is not merely rhetorical. It is a theory grounded as the foundation for a doctoral dissertation: that perhaps 90% of modern chronic disease—including many infectious diseases—or, in this case, atrial fibrillation, and the 20 characteristic signs of metabolic syndrome (including sleep apnea), are in fact the result of the prolonged, unremitting expression of the same adaptive metabolic syndrome our species developed at least 30,000 years ago to survive chronic food insecurity—when humans evolved to endure, with stoic resilience, an incomplete, imbalanced, inadequate meal only every 36 hours on average, thus securing the survival of our species.
What if atrial fibrillation, like virtually all cardiovascular diseases, cancers, and neurodegenerative disorders, is simply a terminal or distal event in this chronic metabolic syndrome—now dysregulated and anachronistic in our era of caloric abundance—whose intermediate causal substrate is persistent obesity?
If this were true, Dr. Mandrola, what would be the point of performing an ablation on a patient with uncontrolled metabolic syndrome without ever addressing the most primordial cause: what they put in their mouth?
Consider the sensationalist TV show starring bariatric surgeon Younan Nowzaradan, which frames the “magical” solution to morbid obesity in weight-loss surgery. The show does acknowledge psychological trauma and childhood sexual abuse as triggers of compulsive overeating and sends patients to therapists to control their “food anxiety.” Yet it completely overlooks that American society, for over 80 years, has been subjected to a radical transformation and artificialization of its standardized diet—one that is not only highly toxic and nutritionally inadequate but also profoundly addictive, especially regarding refined carbohydrates. This is why, as of 2023, 9 out of 10 American adults lack metabolic health.
In the face of this complex reality—an addiction to substances more than ten times as addictive as cocaine—what is the purpose of ablating a human being’s cardiac conduction system?
Perhaps, by borrowing from Dr. Nowzaradan’s model, we should instead challenge ourselves to create a structured lifestyle intervention program to improve metabolic health in atrial fibrillation patients—using realistic measures: clean water, breathing practices, regular physical activity, restorative sleep, sunlight exposure, supplementation, sexual health, intellectual engagement, and nurturing relationships with others and with the environment—and to verify progress through objective outcome markers (waist circumference, blood pressure, HbA1c, apnea indices, etc.), not merely weight or BMI. Once patients reach that threshold, if still indicated, then and only then consider rewarding them with ablation of their cardiac conduction system.
This paradox reminds us of the insight attributed to Maimonides, whose words echo across centuries:
“The physician should not treat the disease but the patient who is suffering from it.”
In other words, if we fail to address the true roots of illness, all our high-technology interventions risk becoming elaborate ways of missing the point.
I think the GLP's are going to change this dramatically. The other interesting thing about GLP is not only do you lose weight but addictive behavior seems to be reduced in many cases, and this includes the use of alcohol. It would be a fascinating comparison. You don't even have to talk about lifestyle. Just compare GLP initiation at the onset with catheter ablation specifically comparing those who successfully lost weight to the ablation arm. In town, patients were put on the partial meal replacement programs that included a weekly visit with a coach. Substantial weight loss was achieved in those that actually started at the program and what a shocker everything got better. It's still a lot harder than the GLPs. I wonder if it's not unreasonable to give people that option before you take them down the path of an ablation?
This statement is just sad....
"You can ablate the AF, get paid a lot, declare victory and send the patient back to the referring doctor still with diabetes, high blood pressure and impaired quality of life."
And then still make money with repeat visits SBD blood work. A total scam
Nice review of this important trial. The takeaway for me is an all-of-the-above approach: catheter ablation for selected patients who will benefit from the procedure and LFM for everyone. I have had a few patients who chose LFM first and did not return for ablation, but it is the exception. I do tell every patient that LFM will do more for your long-term cardiovascular health than anything I can do and will reduce your risk of needing a repeat procedure. I also include alcohol reduction for habitual daily or binge drinkers.
We all know why rates of a fib and other arrhythmias and heart blocks have increased , and it’s not obesity.
Fred — what is it?
Probably just reflects increased awareness due to more frequent monitoring and the use of wearable devices.
For me, the most troubling statement in this essay is "declare victory and send the patient back to the referring doctor still with diabetes, high blood pressure and impaired quality of life." Given the statistics, it's obvious that obesity causes greater disease burden and lower quality of life. Yet the medical system is organized around highly siloed specialists independently treating different sequelae rather than attacking the underlying causes of illness in a coordinated manner.
wonder why the endpoint was not A burden? seemingly more important