Symptom Burden of Atrial Fibrillation and Its Relation to Interventions and Outcome in Europe

Abstract

BackgroundLittle is known about the association of atrial fibrillation symptom burden with quality of life and outcomes.Methods and ResultsIn the Prevention of Thromboembolic Events–European Registry in Atrial Fibrillation (n=6196 patients with atrial fibrillation; mean±SD age, 71.8±10.4 years; 39.7% women), we assessed European Heart Rhythm Association score symptoms and calculated correlations with the standardized health status questionnaire (EQ‐5D‐5L). Patients were followed up for atrial fibrillation therapies and outcomes (stroke/transient ischemic attack/arterial thromboembolism, coronary events, heart failure, and major bleeding) over 1 year. Most individuals (92%) experienced symptoms. Correlations with health status and quality of life were modest. In multivariable‐adjusted regression models, the dichotomized European Heart Rhythm Association score (intermediate/frequent versus never/occasional symptoms) was associated with cardioversions (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.01–1.45) and catheter ablation (OR, 1.97; 95% CI, 1.44–2.69), and inversely related with heart rate control (OR, 0.80; 95% CI, 0.70–0.92) and heart failure incidence (OR, 1.65; 95% CI, 1.16–2.34). Anxiety was inversely related with stroke/transient ischemic attack/arterial thromboembolism (OR, 0.55; 95% CI, 0.32–0.93), whereas chest pain related positively with coronary events (OR, 2.45; 95% CI, 1.42–4.22). Fatigue (OR, 1.84; 95% CI, 1.30–2.60), dyspnea (OR, 2.33; 95% CI, 1.63–3.33), and anxiety (OR, 1.72; 95% CI, 1.16–2.55) were associated with heart failure incidence. Palpitations were positively associated with cardioversion (OR, 1.32; 95% CI, 1.08–1.61) and ablation therapy (OR, 2.02; 95% CI, 1.48–2.76).ConclusionsA higher symptom burden, in particular palpitations, predicted interventions to restore sinus rhythm. The score itself had limited predictive value, but its individual components were related to different and specific clinical events, and may thus be helpful to target patient management.

2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

“…The EHRA symptom scale is a physician-assessed tool for quantification of AF-related symptoms that is used to guide symptom-driven AF treatment decisions, 228 and has been related to adverse outcomes in more symptomatic patients (score 3 -4) versus those with a score of 1 -2. 228,230 However, it does not consider the symptom dimensions such as anxiety, treatment concerns, and medication adverse effects that are captured by general QoL scales, 230 or the patient-reported symptom-related outcomes. As discrepancies between patient-reported and physician-assessed outcomes are frequently observed, 231 the AF-related treatment decisions also need to be informed by a quantified patient perception of symptoms, but further research is needed to identify optimal tool(s) for capturing this information.…”

“…• Evaluate AF-related symptoms (including fatigue, tiredness, exertional shortness of breath, palpitations, and chest pain) and quantify the patient symptom status using the modified EHRA symptom scale before and after initiation of treatment. 230,232 • Evaluate AF-related symptoms before and after cardioversion of persistent AF to aid rhythm control treatment decisions. 230,232 I C AF = atrial fibrillation; EHRA = European Heart Rhythm Association.…”

“…230,232 • Evaluate AF-related symptoms before and after cardioversion of persistent AF to aid rhythm control treatment decisions. 230,232 I C AF = atrial fibrillation; EHRA = European Heart Rhythm Association. 9 Integrated management of patients with atrial fibrillation…”

Characteristics of symptom burden in atrial fibrillation with concomitant heart failure

“…Compared with the degree of symptom burden, AF patients with concomitant HF were less likely than those without HF to be treated with antiarrhythmic drugs or catheter ablation. A previous study using registry data for AF showed that only palpitations predicted the use of interventions to restore sinus rhythm [17]. Because atypical symptoms are more common in AF patients with HF and severe symptoms are associated with cardiovascular outcomes [18], rhythm control strategies need to be encouraged.…”

Current Recommendations on Atrial Fibrillation: A Comparison of the Recent European and Canadian Guidelines

“…The ESC and CCS guidelines place considerable importance on AF-related symptoms and suggest the use of a symptom score to guide decisions for management of AF, treatments, and patient assessment [1, 2, 7, 8]. The ESC guidelines recommend the modified European Heart Rhythm Association (EHRA ) score, which classifies symptoms as none (score 1), mild (score 2A), moderate (score 2B), severe (score 3), and disabling (score 4) [1].…”