The European Heart Rhythm Association symptom classification for atrial fibrillation: validation and improvement through a simple modification

Abstract

AimsTo validate the European Heart Rhythm Association (EHRA) symptom classification in atrial fibrillation (AF) and test whether its discriminative ability could be improved by a simple modification.Methods and resultsWe compared the EHRA classification with three quality of life (QoL) measures: the AF-specific Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) questionnaire; two components of the EQ-5D instrument, a health-related utility which can be used to calculate cost-effectiveness, and the visual analogue scale (VAS) which demonstrates patients' own assessment of health status. We then proposed a simple modification [modified EHRA (mEHRA)] to improve discrimination at the point where major treatment decisions are made. quality of life data and clinician-allocated EHRA class were prospectively collected on 362 patients with AF. A step-wise, negative association was seen between the EHRA class and both the AFEQT and the VAS scores. Health-related utility was only significantly different between Classes 2 and 3 (P < 0.001). We developed and validated the mEHRA score separating Class 2 (symptomatic AF not limiting daily activities), based on whether the patients were ‘troubled by their AF’ (Class 2b) or not (Class 2a). This produced two distinct groups with lower AFEQT and VAS scores and, importantly, both clinically and statistically significant lower health utility (Δutility 0.9, P = 0.01) in Class 2b than Class 2a.ConclusionBased on patients' own assessment of their health status and the disease-specific AFEQT, the EHRA score can be considered a useful semi-quantitative classification. The mEHRA score has a clearer separation in health utility to assess the cost efficacy of interventions such as ablation, where Class 2b symptoms appear to be the appropriate treatment threshold.

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Podobną skalę (Canadian Cardiovascular Society Severity of Atrial Fibrillation Scale) stosuje się w Kanadzie [193]. Skala EHRA jest stosowana i poddano ją walidacji [194][195][196][197][198][199]. W 2014 roku zaproponowano jej modyfikację, dzielącą klasę 2 na podgrupy niewielkiego (2a) oraz umiarkowanego (2b) wpływu na zwykłą aktywność [199].…”

“…Skala EHRA jest stosowana i poddano ją walidacji [194][195][196][197][198][199]. W 2014 roku zaproponowano jej modyfikację, dzielącą klasę 2 na podgrupy niewielkiego (2a) oraz umiarkowanego (2b) wpływu na zwykłą aktywność [199]. Ponieważ objawy odpowiadające klasie 2b (objawy "dolegliwe" dla pacjenta) identyfikowały pacjentów, którzy w tym badaniu odnosili korzyści z kontroli rytmu serca, ta modyfikacja może stworzyć próg dla potencjalnych decyzji terapeutycznych, który wymaga niezależnej walidacji.…”

Defining the major health modifiers causing atrial fibrillation: a roadmap to underpin personalized prevention and treatment

“…Rate-control therapy is titrated on the basis of resting heart rate and symptoms, without individualized discrimination between patients. Only symptoms and, to some degree, the temporal pattern of AF, comorbidities, and life expectancy, are considered when making the decision about rhythm-control therapy 25 . Even the 'simple' distinction between paroxysmal and chronic AF is often incorrect, and correlates poorly with the real AF burden 26,27 .…”

New-Onset Atrial Fibrillation in Settings of Acute Coronary Syndrome. Current Issues

“…Наличие ФП может вызывать у пациентов субъективные ощущения раз-личного характера и степени выраженности. Для оценки выраженности симптомов, сопровождающих ФП, была разработана шкала EHRA [21]. Согласно ре-комендациям Европейского общества кардиологов, асимптомная, или «немая» ФП часто встречается в общей популяции [22,23], а по данным ряда иссле-дований -у пациентов с ИМ в 3 раза чаще симптом-ной ФП [24,25].…”