Symptomatic Asymptomatic Atrial Fibrillation Research Articles

Major clinical outcomes in symptomatic vs. asymptomatic atrial fibrillation: a meta-analysis.

Current guidelines suggest that asymptomatic atrial fibrillation (AF) is independently associated with increased risks of stroke and mortality compared with symptomatic AF. Considering that recent investigations have provided conflicting results, the present study aimed to evaluate the association between symptom status and clinical outcomes in patients with AF. Medline, Cochrane Library, and Scopus were searched until 25 March 2024. Triple-independent study selection, data extraction and quality assessment were performed. Evidence was pooled using random-effects meta-analyses. Thirty-six studies (217 850 participants) were included. Based on the frequentist analysis, symptomatic individuals had no significant difference in the risk of all-cause mortality [hazard ratio (HR) .97, 95% confidence interval (CI) .80-1.17], cardiovascular mortality (HR 1.04, 95% CI .72-1.49), thromboembolism (HR 1.06, 95% CI .87-1.28), stroke (HR 1.06, 95% CI .84-1.34), hospitalization (HR 1.34, 95% CI .89-2.02), and myocardial infarction (HR .98, 95% CI .70-1.36), compared to the asymptomatic group. Symptomatic patients had a 33% increased risk of new-onset heart failure (HR 1.33, 95% CI 1.19-1.49) and a 30% lower risk of progression to permanent AF (HR .70, 95% CI .54-.89). The Bayesian analysis yielded comparable results, yet the association between symptom status and new-onset heart failure was not significant (HR 1.27, 95% credible interval .76-1.93; Bayes factor = 1.2). Symptomatic patients had higher odds of receiving antiarrhythmic drugs (odds ratio [OR] 1.64, 95% CI 1.33-2.03) and ablation therapy (OR 1.47, 95% CI 1.06-2.05) compared to asymptomatic cases. The risk of major clinical outcomes did not differ between individuals with and without AF-related symptoms. Asymptomatic patients had a greater hazard of progression to permanent AF.

Asymptomatic atrial fibrillation among hospitalized patients: clinical correlates and in-hospital outcomes in Improving Care for Cardiovascular Disease in China-Atrial Fibrillation.

The clinical correlates and outcomes of asymptomatic atrial fibrillation (AF) in hospitalized patients are largely unknown. We aimed to investigate the clinical correlates and in-hospital outcomes of asymptomatic AF in hospitalized Chinese patients. We conducted a cross-sectional registry study of inpatients with AF enrolled in the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation Project between February 2015 and December 2019. We investigated the clinical characteristics of asymptomatic AF and the association between the clinical correlates and the in-hospital outcomes of asymptomatic AF. Asymptomatic and symptomatic AF were defined according to the European Heart Rhythm Association score. Asymptomatic patients were more commonly males (56.3%) and had more comorbidities such as hypertension (57.4%), diabetes mellitus (18.6%), peripheral artery disease (PAD; 2.3%), coronary artery disease (55.5%), previous history of stroke/transient ischaemic attack (TIA; 17.9%), and myocardial infarction (MI; 5.4%); however, they had less prevalent heart failure (9.6%) or left ventricular ejection fractions ≤40% (7.3%). Asymptomatic patients were more often hospitalized with a non-AF diagnosis as the main diagnosis and were more commonly first diagnosed with AF (23.9%) and long-standing persistent/permanent AF (17.0%). The independent determinants of asymptomatic presentation were male sex, long-standing persistent AF/permanent AF, previous history of stroke/TIA, MI, PAD, and previous treatment with anti-platelet drugs. The incidence of in-hospital clinical events such as all-cause death, ischaemic stroke/TIA, and acute coronary syndrome (ACS) was higher in asymptomatic patients than in symptomatic patients, and asymptomatic clinical status was an independent risk factor for in-hospital all-cause death, ischaemic stroke/TIA, and ACS. Asymptomatic AF is common among hospitalized patients with AF. Asymptomatic clinical status is associated with male sex, comorbidities, and a higher risk of in-hospital outcomes. The adoption of effective management strategies for patients with AF should not be solely based on clinical symptoms.

Prognostic impact of catheter ablation in patients with asymptomatic atrial fibrillation.

Catheter ablation for asymptomatic atrial fibrillation (AF) remains controversial. The aim of the present study was to explore the prognostic impact of catheter ablation in asymptomatic AF patients. We performed a post-hoc analysis of 537 risk-matched pairs of AF patients receiving first-time catheter ablation or conservative management. The primary outcome measure was a composite of cardiovascular death, heart failure (HF) hospitalization, ischemic stroke, or major bleeding. The study patients were divided into asymptomatic and symptomatic patients, and were further divided according to the presence or absence of previous AF-related complications (ischemic stroke or HF hospitalization). Most baseline characteristics were well balanced between the catheter ablation versus conservative management groups. The median follow-up period was 5.3 years. Catheter ablation as compared to conservative management was associated with significantly lower incidence of the primary outcome measure in the asymptomatic AF patients (14.7% versus 25.4% at 8-year, log-rank P = 0.008). However, the advantage of catheter ablation was significant only in the high-risk subset of patients with the previous AF-related complications (19.2% versus 55.6% at 8-year, log-rank P = 0.006), but not in those without (13.9% and 17.3%, P = 0.08). On the other hand, among the symptomatic AF patients, catheter ablation was associated with significantly lower incidence of the primary outcome measure regardless of the previous AF-related complications. In the post-hoc analysis of the matched AF cohort, catheter ablation as compared with conservative management was associated with better long-term clinical outcomes among asymptomatic AF patients only when the previous AF-related complications were present.

237Role of wearable device recordings in clinical decision making - The wEHRAbles Young EP survey

Abstract Multiple wearable devices for rhythm analysis have been developed using either photoplethysmography (PPG) or handheld ECG. The aim of this survey was to assess how these technologies impact on physicians’ clinical decision-making regarding initiation of diagnostic steps, drug- and interventional therapy. Methods The present survey is conducted with support of the scientific network of EHRA Young EP and will be running from October 1st until December 31st, 2019. The online survey includes 10 questions on types of devices, advantages and disadvantages of wearable devices, gaps in evidence as well as case scenarios for patients with supraventricular arrhythmias, symptomatic and asymptomatic atrial fibrillation (AF). Here, we present preliminary data of the survey. Results So far, a total of 178 physicians from 34 different countries completed the survey. Mean age was 37 ± 8 years. Most participants work in university hospitals (66%) as electrophysiologists (69%) or cardiologists (21%). Most participants would trigger further diagnostic steps if a patient with regular palpitations presented a recording of a regular tachycardia (89% for single-lead ECG vs. 86% for PPG), while a single-lead ECG would be sufficient to perform an invasive EP study in most participants (56% vs. 25% for PPG). Participants would be more reluctant to prescribing antiarrhythmic drug therapy in these patients (29% vs. 10%). In a case scenario of a patient presenting a 30 seconds tracing from a single-lead ECG or PPG device suggesting AF, most participants would trigger further diagnostic steps, Figure 1. A single-lead ECG tracing from a symptomatic AF patient would trigger anticoagulation treatment to a higher extent than in asymptomatic patients (65% vs. 47%). As expected, initiation of antiarrhythmic drug therapy or ablation was suggested to a greater extent in symptomatic patients, Figure 1. PPG tracings would only rarely lead to further therapeutic steps regardless of symptomatology. As main advantages of wearable devices, participants stated faster diagnosis (66%), continuous monitoring opportunities (65%), patient involvement (64%), facilitation of screening (60%) and public availability of monitoring (53%). Main disadvantages participants stated were data overload (67%) and patient-driven instead of clinician-driven screening (43%). Most participants would like to see scientific society recommendations on the use of wearable devices (53%). Conclusion In this ongoing survey the preliminary results show that tracings from wearable devices suggestive of arrhythmias are most likely to trigger further diagnostic steps, and in the case of PPG recordings rarely therapeutic interventions. A majority of participants wanted scientific society recommendations on the use of wearables. Abstract Figure 1

Embolic and Other Adverse Outcomes in Symptomatic Versus Asymptomatic Patients With Atrial Fibrillation (from the ORBIT-AF Registry)

Asymptomatic atrial fibrillation (AF) is being increasingly diagnosed via implantable devices, screening, and inpatient telemetry. Management of asymptomatic AF is controversial, in part, because the associated risks have not been well described. We examined the incidence of major adverse outcomes in patients with asymptomatic versus symptomatic AF using Outcomes Registry for Better Informed Treatment of Atrial, a nationwide US registry of AF patients. We compared stroke and/or non-central nervous system (CNS) embolism, major adverse cardiovascular and neurologic events, bleeding, and death in 9,319 asymptomatic (defined by European Heart Rhythm Association score = 1 or "no symptoms") versus symptomatic patients. Overall, median (interquartile) age was 75 (67 to 82) years, 3,944 (42%) were women, and 38% versus 37% were asymptomatic based on physician versus patient-reported symptoms. Compared with those with symptoms, physician-defined asymptomatic patients were less likely to be woman (35%/47%) or be on an antiarrhythmic agent (22%/33%), but were more likely to have permanent and/or persistent AF (51%/40%). CHA2DS2-VASc scores did not vary by symptom status. After adjustment, risk of first stroke and/or non-CNS embolism (hazard ratio [HR] 0.85 [95% confidence interval {CI} 0.63 to 1.16], p = 0.32), major adverse cardiovascular and neurologic events (HR 0.88 [95% CI 0.76 to 1.03], p = 0.11), bleeding (HR 0.85 [95% CI 0.72 to 1.00], p = 0.05), and death (HR 0.99 [95% CI 0.87 to 1.13], p = 0.88) were similar in asymptomatic (European Heart Rhythm Association = 1) and symptomatic AF, respectively. Prospective, randomized studies are needed to further define associated adverse events and delineate optimal prophylactic therapies in patients with asymptomatic AF.

P3594Stroke risk in patients with asymptomatic atrial fibrillation (AF) detected incidentally in general practice is comparable to symptomatic AF presentation, and AF presenting first to hospital

P3594Stroke risk in patients with asymptomatic atrial fibrillation (AF) detected incidentally in general practice is comparable to symptomatic AF presentation, and AF presenting first to hospital

Relationship between silent atrial fibrillation and the maximum heart rate in the 24-hour Holter: cross-sectional study

Occurrences of asymptomatic atrial fibrillation (AF) are common. It is important to identify AF because it increases morbidity and mortality. 24-hour Holter has been used to detect paroxysmal AF (PAF). The objective of this study was to investigate the relationship between occurrence of PAF in 24-hour Holter and the symptoms of the population studied. Cross-sectional study conducted at a cardiology hospital. 11,321 consecutive 24-hour Holter tests performed at a referral service were analyzed. Patients with pacemakers or with AF throughout the recording were excluded. There were 75 tests (0.67%) with PAF. The mean age was 67 ± 13 years and 45% were female. The heart rate (HR) over the 24 hours was a minimum of 45 ± 8 bpm, mean of 74 ± 17 bpm and maximum of 151 ± 32 bpm. Among the tests showing PAF, only 26% had symptoms. The only factor tested that showed a correlation with symptomatic AF was maximum HR (165 ± 34 versus 147 ± 30 bpm) (P = 0.03). Use of beta blockers had a protective effect against occurrence of PAF symptoms (odds ratio: 0.24, P = 0.031). PAF is a rare event in 24-hour Holter. The maximum HR during the 24 hours was the only factor correlated with symptomatic AF, and use of beta blockers had a protective effect against AF symptom occurrence.

Clinical impact of catheter ablation in patients with asymptomatic atrial fibrillation: The IRON-AF (Italian Registry on NavX Atrial Fibrillation Ablation Procedures) study

Whether and to what extent patients with asymptomatic atrial fibrillation (AF) would benefit from catheter ablation has not been investigated. This is the first multicenter prospective study reporting on the outcome of catheter ablation in patients with asymptomatic AF. Consecutive patients (n = 545) referred for AF ablation were prospectively enrolled in a multicenter Italian registry. Of these patients, 54 have asymptomatic AF and composed our patient population. At 24 month follow-up, catheter ablation in asymptomatic AF patients resulted to be as safe and effective as in patients with drug refractory symptomatic AF. Our study provides significant insights on the role of AF ablation in asymptomatic patients. Further studies in much larger cohorts are needed to validate our conclusions.

Paroxysmal atrial fibrillation with silent episodes: Intermittent versus continuous monitoring

Objectives. Asymptomatic atrial fibrillation (AF) presents the same risk for cardioembolic events as symptomatic AF. Intermittent ECG recordings may be helpful in detecting asymptomatic paroxysmal arrhythmias. The objective of this study was to compare short intermittent heart rhythm recordings with or without symptoms with continuous ECG recordings. Design. Twenty-two patients with diagnosed symptomatic paroxysmal AF participated. Patients used a handheld transtelephonic ECG device for a 30-day period performing two registrations of 10 seconds per day. Additionally patients were asked to make registrations if arrhythmia symptoms occurred. Patients also performed a 24-hour ambulatory continuous ECG recording during a single twenty-four hours period of the 30 day period. AF was defined as an irregular ventricular rhythm without visible p-waves for at least 10 seconds.Results. 1425 intermittent ECG recordings were performed. AF episodes were diagnosed in 18 (82%) patients compared with 7 (32%) patients using continuous ECG, (p = 0.001). All patients with AF detected by continuous monitoring were also detected by intermittent recordings. Of the episodes, 16% were judged as symptomatic. Conclusion. Short-term ECG registrations over extended time periods seem to be a more sensitive tool, compared with short continuous ECG recordings, for detection of AF episodes.

La fibrillation atriale asymptomatique

Asymptomatic atrial fibrillation (AF) is common, may adversely affect quality of life, and above all can be as serious as symptomatic AF. The prevalence of AF reported in epidemiological studies is significantly underestimated, as asymptomatic AF is often not known about. The efficacy of pharmacological or non-pharmacological treatment is often overestimated if the only aim considered is symptomatic recurrences. Like symptomatic AF, asymptomatic AF justifies anticoagulation, depending on the risk of embolism. Estimating the risk of embolism only from symptomatic episodes may result in unjustified discontinuation of antithrombotic treatment. Finally, frequent asymptomatic episodes may worsen atrial or even ventricular remodelling and result in tachycardia-induced cardiomyopathy.

Event‐Recorder Monitoring in the Diagnosis of Atrial Fibrillation in Symptomatic Patients: Subanalysis of the SOPAT Trial

In the SOPAT (suppression of paroxysmal atrial tachyarrhythmias) trial, a high number of asymptomatic atrial fibrillation (AF) episodes were registered in patients with symptomatic AF. This subanalysis was performed to answer three questions: (1) Does antiarrhythmic therapy influence the ratio of symptomatic to asymptomatic AF? (2) Are symptoms during AF dependent on the heart rate (HR)? (3) Do symptoms correlate with an episode of AF? Within 60 months 1,033 patients with symptomatic AF were randomized to either quinidine plus verapamil (Q+V) 480/240 mg/day, Q+V 320/160 mg/day, sotalol 320 mg/day, or placebo, and followed up by daily and symptom-triggered ECG event recording. Over 188,634 ECGs were analyzed (87% SR, 7% AF). Symptoms were reported in only 46% of AF-ECGs. Quinidine plus verapamil reduced the ratio of symptomatic to asymptomatic AF, whereas sotalol had no effect (median [%] (25/75% quartile): Q+V 480/240: 33 (0/79), Q+V 320/160: 45 (1/82), sotalol: 56 (7/93), placebo: 63 (8/92)). The HR during AF directly correlates with the occurrence of symptoms (P < 0.001) and was significantly lower during asymptomatic AF in all groups (mean +/- SD: sympt.: 113 +/- 27/minute, asympt.: 103 +/- 27/minute, P < 0.001). Both antiarrhythmics reduced the mean HR compared to placebo (P < 0.001). Analyzing all symptom-triggered ECGs, AF was diagnosed in only 37%, whereas the majority were SR. Taken together, in contrast to sotalol, Q+V reduces the ratio of symptomatic to asymptomatic AF compared with placebo, at least in part by decreasing the heart rate. Furthermore, patients' symptoms are not a reliable surrogate parameter for the prevalence of AF.

ASymptomatic atrial fibrillation and Stroke Evaluation in pacemaker patients and the atrial fibrillation Reduction atrial pacing Trial (ASSERT)

Asymptomatic atrial fibrillation (AF) is common and may have the same prognostic implications as symptomatic AF. Among patients receiving dual-chamber pacemakers, it is now possible to quantify asymptomatic AF accurately. Most of these episodes are of short duration, often lasting only seconds to minutes and are called atrial high-rate episodes (AHRE) to distinguish them from the longer episodes of overt AF. To understand properly the clinical importance of asymptomatic AF, a large study of pacemaker patients without clinically overt AF is required. ASSERT is a multicenter, cohort follow-up, and single-blinded randomized trial in elderly hypertensive patients with a pacemaker recently implanted for sinus or atrioventricular node disease. The goals of this trial are to evaluate whether the detection of AHRE with pacemaker telemetry predicts an increased risk of stroke and other vascular events and to evaluate if atrial overdrive pacing reduces symptomatic AF. ASSERT is evaluating the hypothesis that among pacemaker patients without a previous history of AF, detection of AHRE predicts an increased risk of stroke and systemic embolism. The second hypothesis to be tested is that overdrive atrial pacing will reduce the risk of symptomatic AF in pacemaker patients without a previous history of AF. Finally, a 400-patient substudy will use the noninvasive testing capabilities of the patients' pacemaker to evaluate changes in atrial electrophysiology over 2 years. This substudy will determine if atrial electrical remodeling is detectable in pacemaker patients and if it is associated with the development of AF.