Rhythm- or rate-control strategies according to 4S-AF characterization scheme and long-term outcomes in atrial fibrillation patients: the FAMo (Fibrillazione Atriale in Modena) cohort

Abstract

The 4S-AF scheme [Stroke risk, Symptom severity, Severity of atrial fibrillation (AF) burden, Substrate severity] was recently proposed to characterize AF patients. In this post hoc analysis we evaluated the agreement between the therapeutic strategy (rate or rhythm control, respectively), as suggested by the 4S-AF scheme, and the actual strategy followed in a patients cohort. Outcomes of interest were as follows: all-cause death, a composite of all-cause death/any thromboembolism/acute coronary syndrome, and a composite of all-cause death, any thrombotic/ischemic event, and major bleeding (net clinical outcome). We enrolled 615 patients: 60.5% male, median age 74 [interquartile range (IQR) 67-80] years; median CHA 2 DS 2 VASc 4 and median HAS-BLED 2. The 4S-AF score would have suggested a rhythm-control strategy in 351 (57.1%) patients while a rate control in 264 (42.9%). The strategy adopted was concordant with the 4S-AF suggestions in 342 (55.6%) cases, and non-concordant in 273 (44.4%). After a median follow-up of 941 days (IQR 365-1282), 113 (18.4%) patients died, 158 (25.7%) had an event of the composite endpoint. On adjusted Cox regression analysis, when 4S-AF score suggested rate control, disagreement with that suggestion was not associated with a worse outcome. When 4S-AF indicated rhythm control, disagreement was associated with a higher risk of all-cause death (HR 7.59; 95% CI 1.65-35.01), and of the composite outcome (HR 2.69; 95% CI 1.19-6.06). The 4S-AF scheme is a useful tool to comprehensively evaluate AF patients and aid the decision-making process. Disagreement with the rhythm control suggestion of the 4S-AF scheme was associated with adverse clinical outcomes.

Dronedarone for the treatment of atrial fibrillation with concomitant heart failure and preserved or mildly reduced ejection fraction: closer to Ithaca after a long odyssey?

“…In summary, the net clinical benefit found in the ATHENA sub‐study for dronedarone in patients with AF and HFpEF or HFmrEF suggests to consider that dronedarone may have a role in this relatively unexplored clinical setting 6 . This suggestion is also in line with the recommendations of current AF guidelines to follow the ABC pathway, where C (comorbidities) implies a more precise assessment of HF, in terms of extent of left ventricular systolic function impairment and associated conditions, with the goal of achieving a more personalized choice between rate and rhythm control strategies 14–16 . In a general view, taking into account all the contributions of the literature 1,2 and clinical experience, the use of dronedarone should consider a series of advantages and limitations, as depicted in Figure .…”

“…6 This suggestion is also in line with the recommendations of current AF guidelines to follow the ABC pathway, where C (comorbidities) implies a more precise assessment of HF, in terms of extent of left ventricular systolic function impairment and associated conditions, with the goal of achieving a more personalized choice between rate and rhythm control strategies. [14][15][16] In a general view, taking into account all the contributions of the literature…”

Chronic Kidney Disease with Mild and Mild to Moderate Reduction in Renal Function and Long-Term Recurrences of Atrial Fibrillation after Pulmonary Vein Cryoballoon Ablation

“…Despite the fact that the dosing of direct oral anticoagulants has been validated on the basis of the Cockroft–Gault formula for estimating creatinine clearance [ 36 ], CKD-EPI, the formula used in the present analysis, is widely accepted for appropriate categorization of renal function, and has the advantage of being easily accessible, in contrast to the cystatin-based equations which have been shown to be more accurate [ 37 , 38 , 39 ]. Patients with advanced CKD have a more complex clinical profile and, therefore, a comprehensive approach is required, in line with the ABC pathway suggested by the most recent guidelines, taking care of the entire patient profile and comorbidities [ 32 , 40 , 41 , 42 , 43 , 44 ].…”

Atrial cardiomyopathy: a derangement in atrial volumes, geometry, function, and pathology with important clinical implications

“…with the most recent ESC 2020 Guidelines 24 advising clinicians to improve atrial fibrillation characterization through the novel 4S-atrial fibrillation scheme, [25][26][27][28] which aims to better analyze the arrhythmia and the atrial substrate. This scheme is meant to be combined with the 'Atrial fibrillation Better Care' pathway, which streamlines a structured, holistic, and integrated approach to patient management.…”