Clinical Classifications of Atrial Fibrillation Poorly Reflect Its Temporal Persistence
Open accessAbstract
Objectives This study aimed to identify how accurately the current clinical atrial fibrillation (AF) classifications reflect its temporal persistence.Background Clinical classification of AF is employed to communicate its persistence, to select appropriate therapies, and as inclusion criterion for clinical trials.Methods Cardiac rhythm histories of 1,195 patients (age 73.0 ± 10.1 years, follow-up: 349 ± 40 days) with implantable devices were reconstructed and analyzed. Patients were classified as having paroxysmal or persistent AF by physicians at baseline in accordance with current guidelines. AF burden, measured as the proportion of time spent in AF, was obtained from the device. Additionally we evaluated the agreement between clinical and device-derived AF classifications.Results Patients within the same clinical class were highly heterogeneous with regards to AF temporal persistence. Agreement between the clinical AF classification and the objective device-derived assessments of AF temporal persistence was poor (Cohen's kappa: 0.12 [95% CI: 0.05 to 0.18]). Patient characteristics influenced the clinical decision to classify AF as paroxysmal or persistent. Higher ejection fraction (odds ratio: 0.97/per unit [95% CI: 0.95 to 0.98/per unit]; p < 0.0001) and presence of coronary artery disease (odds ratio: 0.53 [95% CI: 0.32 to 0.88]; p = 0.01) were independently associated with a lower probability of being classified as persistent AF for the same AF burden level.Conclusions The currently used clinical AF classifications poorly reflect AF temporal persistence. Patient characteristics significantly influence the physician's classification of AF. Patients classified in identical clinical categories may be inherently heterogeneous with regard to AF temporal persistence. Further study is required to determine if patient selection on the basis of objective criteria derived from rigorous AF monitoring can improve reported outcomes and better identify responders and non-responders to treatments. (OMNI Study-Assessing Therapies in Medtronic Pacemaker, Defibrillator, and Cardiac Resynchronization Therapy Devices; NCT00277524; TRENDS: A Prospective Study of the Clinical Significance of Atrial Arrhythmias Detected by Implanted Device Diagnostics; NCT00279981).
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Reliance on symptoms alone by patient or physician may be misleading, both over- and underestimating the presence of AF.
“Reliance on symptoms alone (by patient or physician) may be misleading-both over and underestimating the presence of AF (Charitos et al., 2014).”
From 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry (2017) · cites this paper as Charitos et al., 2014
In “The influence of symptomatology on AF classification” (page not provided), the paper says symptoms may influence physicians’ classifications and poorly correlate with how persistently AF occurs. This supports the warning that symptoms can mislead, but the paper does not establish that reliance on symptoms alone both over- and underestimates whether AF is present. (LLM, conf=0.82)
Experimental — accuracy not yet measuredClinically determined AF patterns do not correspond well to the AF burden measured by long-term ECG monitoring.
“Clinically determined AF patterns do not correspond well to the AF burden measured by long-term ECG monitoring.163”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [163]
Asymptomatic AF is often undiagnosed and is likely underdiagnosed in this study.
“Asymptomatic AF is often undiagnosed41 and is likely underdiagnosed in this study as well.”
From Twelve-single nucleotide polymorphism genetic risk score identifies individuals at increased risk for future atrial fibrillation and stroke (2014) · cites this paper as [41]
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- Authors
- Charitos, E. I., Pürerfellner, H., Glotzer, T. V., & Ziegler, P. D.
- Affiliations
- University of Lübeck (DE)
- Krankenhaus der Elisabethinen (AT)
- Hackensack University Medical Center (US)
- Medtronic (United States) (US)
- Corresponding author
- Charitos, Efstratios I.
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2014-07
- Volume
- 63
- Issue
- 25
- Pages
- 2840-2848
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W191924134
- Cited by
- 188
- References
- 35
- Citations by year
- 2026: 10 · 2025: 16 · 2024: 23 · 2023: 11 · 2022: 14 · 2021: 20 · 2020: 15 · 2019: 9 · 2018: 17 · 2017: 18 · 2016: 13 · 2015: 15 · 2014: 7
- FWCI
- 12.12
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Keywords
- atrial fibrillation, temporal persistence, clinical classification, paroxysmal atrial fibrillation, persistent atrial fibrillation, atrial fibrillation burden, cardiac implantable electronic devices, ejection fraction, coronary artery disease, patient selection
- MeSH terms
- Aged, Atrial Fibrillation, Equipment Design, Female, Heart Rate, Humans, Male, Middle Aged, Monitoring, Physiologic, Prospective Studies, Treatment Outcome, Cardiac Resynchronization Therapy Devices
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