Clinical classification and the subclinical atrial fibrillation challenge: a position paper of the European Cardiac Arrh
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Clinical classification and the subclinical atrial fibrillation challenge: a position paper of the European Cardiac Arrhythmia Society Samuel Lévy 1
&
Luca Santini 2 & Riccardo Cappato 3 & Gerhard Steinbeck 4 & Alessandro Capucci 5 & Sanjeev Saksena 6
Received: 14 August 2020 / Accepted: 26 August 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Symptomatic atrial fibrillation (AF) or clinical AF is associated with impaired quality of life, higher risk of stroke, heart failure, and increased mortality. Current clinical classification of AF is based on the duration of AF episodes and the recurrence over time. Appropriate management strategy should follow guidelines of Scientific Societies. The last decades have been marked by the advances in mechanism comprehension, better management of symptomatic AF, particularly regarding stroke prevention with the use of direct oral anticoagulants and a wider use of AF catheter or surgical ablations. The advent of new tools for detection of asymptomatic AF including continuous monitoring with implanted electronic devices and the use of implantable cardiac monitors and recently wearable devices or garments have identified what is called “subclinical AF” encompassing atrial high-rate episodes (AHREs). New concepts such as “AF burden” have resulted in new management challenges. Oral anticoagulation has proven to reduce substantially stroke risk in patients with symptomatic clinical AF but carries the risk of bleeding. Management of detected asymptomatic atrial arrhythmias and their relation to clinical AF and stroke risk is currently under evaluation. Based on a review of recent literature, the validity of current clinical classification has been reassessed and appropriate updates are proposed. Current evidence supporting the inclusion of subclinical AF within current clinical classification is discussed as well as the need for controlled trials which may provide responses to current therapeutic challenges particularly regarding the subsets of asymptomatic AF patients that might benefit from oral anticoagulation. Keywords Atrial fibrillation . Clinical classification . Subclinical AF . AF screening . Device-derived AF . Oral anticoagulants . Stroke risk . Cryptogenic stroke
1 Introduction Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in daily practice and represents an increasing
* Samuel Lévy [email protected] 1
Marseille School of Medicine, Aix-Marseille University, Marseille, France
2
Cardiology Division, G. B. Grassi Hospital, Via G. Passeroni 28, Ostia Lido, RM, Italy
3
Arrhythmia and Elecrtrophysiology Center, IRCCS-MultiMedica Group, Via Milanese 300, 20099 Milan, Sesto San Giovanni, Italy
4
Ludwig Maximilians University, Munich, Germany
5
Department of Cardiology, Università Politecnica delle Marche, Ancona, Italy
6
Rutgers-Robert Wood Johnson Medical School, Piscataway, NJ, USA
epidemic related to aging population in the Western World and in developing countries [1, 2]. Symptom
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