Treating gum disease during AFib blanking period could reduce recurrence risk

In a recent study published in the Journal of the American Heart Association, researchers assessed whether periodontal treatment during the blanking period enhances the success rate of atrial fibrillation (AF) ablation in patients with periodontitis.

Study: Periodontal Treatment During the Blanking Period Improves the Outcome of Atrial Fibrillation Ablation. Image Credit: Lightspring / Shutterstock

Background 

AF is the most common arrhythmia, increasing risks of stroke, heart failure, and premature death, thus reducing healthy life expectancy. While radiofrequency catheter ablation (RFCA) offers a higher AF recurrence-free survival rate than antiarrhythmic drugs, recurrences are common, especially in nonparoxysmal AF cases. Effective management of modifiable risk factors such as obesity, sleep apnea, diabetes, and hypertension is critical for improving RFCA outcomes. Unlike these established factors, periodontitis has not yet been recognized as a modifiable risk factor for AF despite its association with AF occurrence and recurrence. 

Further research is needed to establish a definitive causal link between periodontal treatment and improved outcomes in AF ablation, potentially leading to new preventative strategies.

About the study 

The present nonrandomized study conducted at Hiroshima University Hospital from April 1, 2020, to July 31, 2022, enrolled 330 consecutive patients with AF admitted for initial RFCA. Patients underwent a periodontal examination the day before RFCA, where the periodontal inflamed surface area (PISA) was assessed to quantify periodontitis severity. Those consenting underwent recommended nonsurgical periodontal treatment during the blanking period, especially at 1 and 3 months post-RFCA. The study adhered to the principles of the Declaration of Helsinki and received ethical approval from the Hiroshima University Ethics Committee. Prior to participation, written informed consent was secured from all patients. 

Periodontal status was evaluated by a dental clinician using standard methods to measure inflammation and disease extent. This treatment consisted of comprehensive oral hygiene instruction and full-mouth debridement without interrupting anticoagulation, showcasing no observed complications. Furthermore, the study also ventured into measuring serum antibody titers against major periodontal pathogens and inflammatory cytokines, providing a more detailed insight into the systemic impact of periodontal health.

Electrophysiological studies and RFCA procedures were executed with the operators blind to the patient’s periodontal health status, ensuring unbiased treatment and observation. Carefully planned follow-ups aimed to identify AF recurrence with methodologies, including Electrocardiogram (ECG) and Holter monitoring. 

Study results 

The present study involved 288 patients undergoing initial RFCA, and out of these,190 (66%) were men, and 163 (57%) had paroxysmal AF. During the average follow-up of 507±256 days, AF recurred in 70 (24%) patients. Among the participants, 97 received periodontal treatment during the blanking period, while 191 did not. Baseline characteristics, including the PISA, showed significant differences only in PISA values, with the treatment group having a higher baseline PISA than the non-treatment group. Other factors, such as pre-and post-RFCA antiarrhythmic drug use, RFCA procedures, and complications, showed no significant differences between the groups.

Inflammatory markers and their relation to AF recurrences were assessed. Baseline serum levels of high-sensitivity C-reactive protein (hs-CRP) and various interleukins (IL-1β, IL-4, IL-6, IL-10, and IL-17A) were significantly higher in patients who experienced AF recurrences within 12 months. However, these markers did not correlate with early AF recurrences. The study also evaluated the link between periodontitis and AF recurrence, revealing that patients with higher PISA were more likely to experience recurrences. Receiver operating characteristic analysis yielded a PISA cutoff of 615.8 mm², categorizing patients into high and low PISA groups. Those in the high PISA group showed significantly lower AF recurrence-free survival rates.

Further analyses highlighted the systemic inflammation associated with high PISA levels, with these patients displaying significantly elevated serum levels of inflammatory cytokines. Periodontal treatment appeared to significantly improve PISA scores, particularly in those with initially high PISA. Kaplan-Meier analyses demonstrated that the treatment group experienced fewer AF recurrences compared to the non-treatment group within 12 months, particularly those with high baseline PISA.

In terms of specific periodontal pathogens, the presence of Porphyromonas gingivalis and Fusobacterium nucleatum was linked to higher rates of AF recurrence in patients with nonparoxysmal AF. This suggests a potential role of these pathogens in the recurrence of AF post-ablation.

Conclusions 

To summarize, this study examined the role of the PISA in predicting AF recurrence post-RFCA and assessed the impact of periodontal treatment during the blanking period. Findings suggest that high PISA values correlate with increased AF recurrence risk, positioning periodontitis as a potentially modifiable risk factor for AF. The research highlights a significant link between systemic inflammation induced by periodontitis and AF pathogenesis, advocating for integrating dental health into AF management. Periodontal treatment reduced recurrence rates, emphasizing the need for comprehensive management strategies that include dental care.