Clinical Vulnerability Refines Rhythm‐Related Outcomes in Older Patients Undergoing Pulmonary Vein Isolation for Atrial Fibrillation: An Observational Cohort Study

ABSTRACT Introduction Chronological age is often considered when selecting patients for atrial fibrillation (AF) ablation, but age alone may not identify which older patients are most likely to require recurrent rhythm‐related care after pulmonary vein isolation (PVI). Methods We conducted a single‐center observational study of consecutive patients undergoing PVI. The principal registry cohort assessed the same‐center recurrence‐related rhythm‐intervention endpoint, defined as the first post‐index repeat PVI or electrical cardioversion. A nested active 2022 cohort assessed broader actively ascertained recurrence. Age was analyzed as < 50, 50–74, and ≥ 75. An exploratory elderly vulnerability score assigned one point each for documented persistent AF, heart failure, chronic kidney disease, and valve disease/surgery. Results The registry cohort included 2559 patients and 580 same‐center rhythm‐intervention events. Event rates increased across age groups: 14.2% in patients aged < 50, 20.8% in those aged 50–74, and 29.8% in those aged ≥ 75. Age ≥ 75 was independently associated with higher risk versus age 50–74 in adjusted registry Cox analysis, HR: 1.35, 95% CI: 1.12–1.64, p = 0.002, after 90‐day blanking, HR: 1.37, 95% CI: 1.12–1.69, p = 0.002, and in the active cohort, HR: 1.46, 95% CI: 1.01–2.11, p = 0.042. Elderly Score 0 patients were not significantly different from patients aged 50–74 in registry analysis, aHR: 1.13, 95% CI: 0.79–1.63, p = 0.5, or active analysis, aHR: 1.01, 95% CI: 0.49–2.09, p = 0.975, whereas Score ≥ 2 identified higher event burden in both the registry cohort, aHR: 1.85, 95% CI: 1.45–2.35, p < 0.001, and active cohort, aHR: 1.95, 95% CI: 1.23–3.12, p = 0.005. Conclusion Age ≥ 75 was associated with a higher rate of same‐center recurrence‐related rhythm interventions after PVI, but the risk varied substantially. Clinical vulnerability, not chronological age alone, may better inform counseling and selection of older patients.