Asymptomatic persistent atrial fibrillation and outcome: Results of the RACE study
Introduction
Atrial fibrillation (AF) may be accompanied by symptoms, impaired quality of life, and an increased risk of stroke, dementia, heart failure, and death.1 Although most patients with AF have symptoms, approximately 15%–30% of the patients diagnosed with clinical AF appear asymptomatic.2, 3 In patients with pacemaker and ICD and without a clinical diagnosis of AF, but at risk for AF, the incidence of (short) episodes of high atrial rates and silent AF is even higher.4, 5 At present, it remains uncertain why some patients with AF are asymptomatic and others are symptomatic and whether the presence of symptoms is associated with prognosis. It has been observed that in older patients, symptoms may decrease or disappear with longer durations of the arrhythmia.2, 3, 6 Somatic, psychological factors and the presence of other cardiovascular conditions that may present with similar symptoms or aggravate symptoms are likely to contribute to the complex relation between symptoms and AF.3, 7 The latest guidelines of the European Society of Cardiology identifies “asymptomatic AF” as a specific clinical form and recommend classification using the European Heart Rhythm Association score of AF-related symptoms.1, 8 Classification of AF according to symptom burden is important since large randomized trials have demonstrated that the outcome of rate control vs rhythm control therapies is similar9, 10 and choice for a rate or rhythm control treatment strategy is largely driven by the degree of AF-related symptoms. Also, symptom burden is important to guide therapy and evaluate success of especially rhythm control strategies.
At present, it is uncertain whether simple awareness of symptoms can be used as a prognostic marker for specific cardiovascular outcomes in patients known and treated for AF. We sought to investigate potential differences in the clinical profile and prognosis of asymptomatic and symptomatic patients with recurrent persistent AF, as included in the RAte Control versus Electrical cardioversion for persistent atrial fibrillation (RACE) study.10
Section snippets
Study design
Study design, patient characteristics, and results of the RACE study have been published previously.10 In short, 522 patients (157 [30%] patients with asymptomatic AF) with recurrent persistent AF were included and randomized to rate or rhythm control. Patients were followed for at least 2 years with a maximum of 3 years. The follow-up scheme is described in Online Supplemental Methods.
Administration of a β-blocker, a nondihydropyridine calcium-channel blocker, or digitalis, alone or in
Patient characteristics
At randomization, 157 of 522 (30%) patients had asymptomatic persistent AF. The other 365 (70%) patients had at least 1 AF-related symptom: palpitations (n = 143 [39%]), dyspnea (n = 185 [51%]), fatigue (n = 207 [57%]), angina pectoris (n = 34 [9%]), presyncope (n = 13 [4%]), or other complaints (n = 73 [20%]). Patients with asymptomatic AF were younger and more often men (Table 1). Concomitant cardiovascular conditions as coronary artery disease and cardiomyopathy were less common in patients
Discussion
In the present post hoc analysis of the RACE study,10 we observed that patients with asymptomatic persistent AF had less cardiovascular diseases and the composite primary end point, mainly driven by heart failure hospitalizations and severe adverse effects of antiarrhythmic and rate control drugs, occurred less frequently than in patients with symptomatic AF. In multivariate analysis after adjusting for differences in clinical characteristics, medication use, and echocardiographic measurements,
Conclusion
Patients with asymptomatic persistent AF had less cardiac disease, and when treated, they had less heart failure hospitalizations and severe adverse effects of antiarrhythmic drugs and rate control drugs as compared with those with symptomatic AF. Future studies are warranted to further clarify the mechanisms underlying AF symptoms and prognosis.
References (31)
- et al.
Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study
Am Heart J
(2005) - et al.
Effect of rate or rhythm control on quality of life in persistent atrial fibrillation
J Am Coll Cardiol
(2004) - et al.
Gender-related differences in rhythm control treatment in persistent atrial fibrillation: data of the Rate Control Versus Electrical Cardioversion (RACE) study
J Am Coll Cardiol
(2005) - et al.
The effect of rate control on quality of life in patients with permanent atrial fibrillation: data from the RACE II (Rate Control Efficacy in Permanent Atrial Fibrillation II) study
J Am Coll Cardiol
(2011) - et al.
Gender-related differences in presentation, treatment, and outcome of patients with atrial fibrillation in Europe: a report from the Euro Heart Survey on Atrial Fibrillation
J Am Coll Cardiol
(2007) - et al.
Role of gender and personality on quality-of-life impairment in intermittent atrial fibrillation
Am J Cardiol
(2000) - et al.
Gender differences and quality of life in atrial fibrillation: the mediating role of depression
J Psychosom Res
(2006) - et al.
rate control efficacy in permanent atrial fibrillation: successful and failed strict rate control against a background of lenient rate control: data from RACE II (Rate Control Efficacy in Permanent Atrial Fibrillation)
J Am Coll Cardiol
(2013) - et al.
Progression from paroxysmal to persistent atrial fibrillation clinical correlates and prognosis
J Am Coll Cardiol
(2010) - et al.
The impairment of health-related quality of life in patients with intermittent atrial fibrillation: implications for the assessment of investigational therapy
J Am Coll Cardiol
(2000)
Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC)
Eur Heart J
Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. The College of French Cardiologists
Circulation
Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia
Circulation
Subclinical atrial fibrillation and the risk of stroke
N Engl J Med
Atrial fibrillation management: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation
Eur Heart J
Cited by (0)
The first 2 authors contributed equally to this work.
This work was supported by grants from the Center of Health Care Insurance (OG96-047) and the Interuniversity Cardiology Institute, The Netherlands, and by an unrestricted grant from 3M Pharma, The Netherlands.