Highlights
- The DECAF randomized clinical trial found that caffeinated coffee consumption (averaging 1 cup per day) was associated with a 39% lower hazard of atrial fibrillation (AF) or atrial flutter recurrence compared to complete caffeine abstinence.
- The study enrolled 200 patients following successful electrical cardioversion, challenging the long-standing clinical dogma that caffeine is a proarrhythmic trigger.
- The primary endpoint of clinically detected recurrence occurred in 47% of the coffee consumption group versus 64% of the abstinence group (HR 0.61; 95% CI, 0.42-0.89; P = .01).
- Safety data indicated no significant difference in adverse events between those who consumed coffee and those who abstained.
Introduction: Re-evaluating the Caffeine-Arrhythmia Link
For decades, one of the most common pieces of advice given by clinicians to patients with atrial fibrillation (AF) has been to avoid caffeine. This recommendation was largely rooted in the theoretical understanding of caffeine as a methylxanthine that increases sympathetic nervous system activity and acts as a phosphodiesterase inhibitor, potentially lowering the threshold for ectopic activity. However, much of this ‘conventional wisdom’ was based on anecdotal evidence or small, uncontrolled observations rather than rigorous clinical trial data.
Coffee is the most widely consumed caffeinated beverage in the United States and globally. As AF reaches epidemic proportions in aging populations, understanding the true impact of lifestyle factors like coffee consumption is critical. The DECAF (Caffeinated Coffee Consumption or Abstinence to Reduce Atrial Fibrillation) randomized clinical trial was designed to provide high-quality evidence to either support or refute the practice of caffeine restriction in the management of AF.
Disease Burden and Clinical Context
Atrial fibrillation is the most common sustained cardiac arrhythmia, associated with significant morbidity, including stroke, heart failure, and cognitive decline. For many patients, electrical cardioversion is a primary strategy to restore sinus rhythm. However, the maintenance of sinus rhythm post-cardioversion remains a significant clinical challenge, with high rates of recurrence often necessitating long-term antiarrhythmic drug therapy or catheter ablation.
Patients are often highly motivated to make lifestyle changes to prevent recurrence. When patients ask about diet and triggers, caffeine is frequently at the top of the list. If caffeine is not actually proarrhythmic—or if it is potentially protective—unnecessary abstinence can lead to reduced quality of life without clinical benefit. The DECAF trial addresses this unmet medical need by providing a randomized comparison of consumption versus abstinence in a high-risk post-cardioversion population.
Study Design and Methodology
The DECAF trial was a prospective, open-label, randomized clinical trial conducted across five major hospitals in the United States, Canada, and Australia. The study enrolled 200 adults who were current or previous coffee drinkers. Participants had persistent AF or atrial flutter with a history of AF and were scheduled for electrical cardioversion.
Intervention and Comparators
Participants were randomized in a 1:1 ratio into two distinct groups:
1. Coffee Consumption Group (n = 100): Patients were encouraged to consume at least one cup of caffeinated coffee daily.
2. Abstinence Group (n = 100): Patients were instructed to completely avoid both caffeinated and decaffeinated coffee, as well as other caffeine-containing products (such as tea, soda, and chocolate).
The follow-up period was six months, with the primary objective of determining the effect of these interventions on the recurrence of AF or atrial flutter. Baseline coffee intake was similar between groups, averaging approximately 7 cups per week.
End Points and Monitoring
The primary end point was the clinically detected recurrence of AF or atrial flutter within the 6-month follow-up period. Adherence was monitored through self-reporting, and the study utilized a rigorous follow-up schedule ending in June 2025.
Key Findings: The Protective Effect of Coffee
The results of the DECAF trial were striking and contrary to traditional expectations. At the end of the 6-month follow-up, there was a significant difference in the primary outcome between the two cohorts.
Primary Outcome: AF/Flutter Recurrence
In the coffee consumption group, 47% of patients experienced a recurrence of AF or atrial flutter. In contrast, 64% of patients in the abstinence group experienced a recurrence. This translated to a hazard ratio (HR) of 0.61 (95% CI, 0.42-0.89; P = .01), indicating a 39% reduction in the risk of recurrence for those who continued to drink caffeinated coffee.
Secondary Analyses and Consistency
When analyzing AF recurrence specifically (excluding isolated atrial flutter), the benefit of coffee consumption remained comparable and statistically significant. The median intake in the consumption group during the trial was 7 cups per week, whereas the abstinence group successfully reduced their intake to a median of 0 cups per week, confirming high adherence to the study protocols.
Safety and Adverse Events
One of the primary concerns with caffeine consumption in cardiac patients is the potential for adverse events such as palpitations, insomnia, or hypertensive urgency. However, the DECAF trial reported no significant differences in adverse event rates between the two groups. This suggests that for the average patient with AF post-cardioversion, moderate coffee consumption is not only safe but potentially beneficial.
Expert Commentary and Mechanistic Insights
How can we reconcile these findings with the long-held belief that caffeine triggers arrhythmias? Several biological mechanisms may explain why coffee could be protective against AF recurrence.
Adenosine Receptor Antagonism
Caffeine is a potent antagonist of adenosine receptors. Adenosine is known to shorten the atrial refractory period, which can facilitate the re-entrant circuits that maintain AF. By blocking these receptors, caffeine may actually lengthen the atrial refractory period, thereby acting as a mild antiarrhythmic agent.
Antioxidant and Anti-inflammatory Properties
Coffee is a complex beverage containing hundreds of bioactive compounds, including polyphenols and antioxidants. Atrial fibrillation is closely linked to oxidative stress and systemic inflammation, which promote atrial remodeling. The antioxidant properties of coffee may mitigate this remodeling process, making the atrial substrate less prone to arrhythmia recurrence.
Clinical Generalizability
It is important to note that the DECAF trial specifically looked at coffee drinkers who had undergone cardioversion. While the results are robust, they may not necessarily apply to patients with highly symptomatic paroxysmal AF who have identified caffeine as a specific, idiosyncratic trigger. However, for the broad population of AF patients, these data suggest that a blanket recommendation for caffeine abstinence is no longer evidence-based.
Conclusion: A Shift in Clinical Practice
The DECAF randomized clinical trial provides high-level evidence that caffeinated coffee consumption, at an average of one cup per day, is associated with a significantly lower rate of AF recurrence after successful cardioversion compared to total abstinence. This study effectively flips the narrative on caffeine and heart rhythm disorders.
For clinicians, the takeaway is clear: rather than reflexively advising AF patients to quit coffee, we should share this evidence that moderate consumption may actually support the maintenance of sinus rhythm. This approach not only aligns with current evidence but also respects the patient’s quality of life and dietary preferences.
Funding and Registration
This study was supported by various institutional grants from the participating centers. The trial is registered at ClinicalTrials.gov with the identifier NCT05121519.
References
1. Wong CX, Cheung CC, Montenegro G, et al. Caffeinated Coffee Consumption or Abstinence to Reduce Atrial Fibrillation: The DECAF Randomized Clinical Trial. JAMA. 2026;335(4):317-325. doi:10.1001/jama.2025.21056.
2. Marcus GM. Caffeine and Arrhythmias: Time to Grind the Conventional Wisdom? Journal of the American College of Cardiology. 2020;75(13):1563-1565.
3. Voskoboinik A, Koh Y, Kistler PM. Cardiovascular effects of curcumin and caffeine: A review. Trends in Cardiovascular Medicine. 2022;32(2):67-75.
