Symptomatic Atrial Fibrillation and Risk of Cardiovascular Events

Data From the Euro Heart Survey

Federico Guerra; Michela Brambatti; Robby Nieuwlaat; Maura Marcucci; Elton Dudink; Harry J.G.M. Crijns; Maria Vittoria Matassini; Alessandro Capucci

Disclosures

Europace. 2017;19(12):1922-1929. 

In This Article

Abstract and Introduction

Abstract

Aims Atrial fibrillation (AF) is associated with a wide range of clinical presentations. Whether and how AF symptoms can affect prognosis is still unclear. Aims of the present analysis were to investigate potential predictors of symptomatic AF and to determine if symptoms are associated with higher incidence of cardiovascular (CV) events at 1-year follow-up.

Methods and results The Euro Heart Survey on Atrial Fibrillation included 3607 consecutive patients with documented AF and available follow-up regarding symptoms status. Patients found symptomatic at baseline were classified into still symptomatic (SS group; n = 896) and asymptomatic (SA; n = 1556) at 1 year. Similarly, asymptomatic patients at baseline were classified into still asymptomatic (AA group; n = 903) and symptomatic (AS group; n = 252) at 1 year. Demographics, as well as clinical variables and medical treatments, were tested as potential predictors of symptoms persistence/development at 1-year. We also compared CV events between SS and SA groups, and AS and AA groups at 1-year follow-up. Both persistence and development of AF symptoms were associated with an increased risk of CV hospitalization, stroke, heart failure worsening, and thrombo-embolism. AF type, hypothyroidism, chronic heart failure, and chronic obstructive pulmonary disease (COPD), were independently associated with an increased risk of symptomatic status at 1-year follow-up between SS and SA groups.

Conclusion Persistence or development of symptoms after medical treatment are associated with an increased risk of CV events during a 1-year follow-up. Type of AF, along with hypothyroidism, COPD and chronic heart failure are significantly associated with symptoms persistence despite medical treatment.

Introduction

Atrial fibrillation (AF) is the most common arrhythmia and is associated with a wide range of clinical presentations. Patients with AF may experience palpitations, dyspnea, chest pain, fatigue, dizziness, and, less commonly, syncope.[1] AF may also be asymptomatic, and thus subclinical, causing no warning to doctor or patient. With the advent of continuous long-term monitoring, it is now well documented that AF occurs in many patients without recognizable symptoms while carrying similar stroke risk as symptomatic patients.[2–4]

It is still unclear why some patients are asymptomatic while others suffer from disabling symptoms. In a sub-analysis of the AFFIRM trial, patients with asymptomatic AF had a less severe cardiac disease compared to symptomatic patients.[2] Symptoms may also decrease when patients are treated with antiarrhythmic therapy, in some cases despite AF recurrence or persistence.[5,6] The SOPAT trial showed an inverse association between symptoms and antiarrhythmic drug therapy, and a direct association between symptoms and high ventricular rates.[7] In some cases, symptoms are not specific for AF because also common in other clinical conditions, such as heart failure, ischaemic cardiomyopathy and other arrhythmias.[8,9] Regardless of reasons, symptoms are often associated with impaired quality of life in patients with AF.[10]

To date, whether and how AF symptoms persistence or development despite medical treatment can affect prognosis is still unclear. The present analysis from the Euro Heart Survey on AF[11] aims to describe clinical presentation and outcomes of AF patients, both symptomatic and asymptomatic at baseline, and to identify clinical predictors of symptoms persistence/development at 1-year follow-up. We tested the hypothesis that persistence or development of symptoms after 1 year, despite medical treatment, may be associated with higher incidence of cardiovascular (CV) events.

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