Natural history of ‘silent’ atrial fibrillation from subclinical to asymptomatic: State of the art and need for research

Abstract

In the last 30 years clinical research in the atrial fibrillation (AF) field has seen a great advance both in terms of productivity and heterogeneity of areas that developed significant new knowledge and evidence. Indeed, it is very easy to verify how in the last 3 decades the number of articles regarding AF registered in MEDLINE has increased exponentially overtime. This large amount of evidence led to significant changes in the guidelines, with an improvement of the overall quality of recommendations and an increase in the high-quality recommendations (despite being still generally low) [ [1] Boriani G. Vitolo M. Lane D.A. Potpara T.S. Lip G.Y. Beyond the 2020 guidelines on atrial fibrillation of the European society of cardiology. Eur J Intern Med. 2021; 86: 1-11https://doi.org/10.1016/j.ejim.2021.01.006 Google Scholar , [2] Barnett A.S. Lewis W.R. Field M.E. Fonarow G.C. Gersh B.J. Page R.L. et al. Quality of evidence underlying the American Heart Association/American College of Cardiology/Heart Rhythm Society Guidelines on the management of atrial fibrillation. JAMA Cardiol. 2017; 2: 319https://doi.org/10.1001/jamacardio.2016.4936 Google Scholar ]. Several areas about AF clinical management are now largely assessed and established, as the need for oral anticoagulant (OAC) prescription, the preference of the non-vitamin K antagonist oral anticoagulants over vitamin k antagonist ones, as well as the assessment of thromboembolic and bleeding risks [ [3] Imberti J.F. Mei D.A. Vitolo M. Bonini N. Proietti M. Potpara T. et al. Comparing atrial fibrillation guidelines: focus on stroke prevention, bleeding risk assessment and oral anticoagulant recommendations. Eur J Intern Med. 2022; 101: 1-7https://doi.org/10.1016/j.ejim.2022.04.023 Google Scholar , [4] Hindricks G. Potpara T. Dagres N. Arbelo E. Bax J.J. Blomström-Lundqvist C. et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021; 42: 373-498https://doi.org/10.1093/eurheartj/ehaa612 Google Scholar ]. Also, the need for implementation of integrated care, emerged as the main AF management strategy in the last guidelines, is now largely assessed and evidence based [ 4 Hindricks G. Potpara T. Dagres N. Arbelo E. Bax J.J. Blomström-Lundqvist C. et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2021; 42: 373-498https://doi.org/10.1093/eurheartj/ehaa612 Google Scholar , 5 Romiti G.F. Pastori D. Rivera-Caravaca J.M. Ding W.Y. Gue Y.X. Menichelli D. et al. Adherence to the “atrial fibrillation better care” pathway in patients with atrial fibrillation: impact on clinical outcomes-a systematic review and meta-analysis of 285,000 patients. Thromb Haemost. 2022; 122: 406-414https://doi.org/10.1055/a-1515-9630 Google Scholar , 6 Romiti G.F. Proietti M. Vitolo M. Bonini N. Fawzy A.M. Ding W.Y. et al. Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry. BMC Med. 2022; 20: 326https://doi.org/10.1186/s12916-022-02526-7 Google Scholar ].