The European Heart Rhythm Association symptom classification for atrial fibrillation: validation and improvement through a simple modification
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AIMS: To validate the European Heart Rhythm Association (EHRA) symptom classification in atrial fibrillation (AF) and test whether its discriminative ability could be improved by a simple modification. METHODS AND RESULTS: We compared the EHRA classification with three quality of life (QoL) measures: the AF-specific Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) questionnaire; two components of the EQ-5D instrument, a health-related utility which can be used to calculate cost-effectiveness, and the visual analogue scale (VAS) which demonstrates patients' own assessment of health status. We then proposed a simple modification [modified EHRA (mEHRA)] to improve discrimination at the point where major treatment decisions are made. quality of life data and clinician-allocated EHRA class were prospectively collected on 362 patients with AF. A step-wise, negative association was seen between the EHRA class and both the AFEQT and the VAS scores. Health-related utility was only significantly different between Classes 2 and 3 (P < 0.001). We developed and validated the mEHRA score separating Class 2 (symptomatic AF not limiting daily activities), based on whether the patients were 'troubled by their AF' (Class 2b) or not (Class 2a). This produced two distinct groups with lower AFEQT and VAS scores and, importantly, both clinically and statistically significant lower health utility (Δutility 0.9, P = 0.01) in Class 2b than Class 2a. CONCLUSION: Based on patients' own assessment of their health status and the disease-specific AFEQT, the EHRA score can be considered a useful semi-quantitative classification. The mEHRA score has a clearer separation in health utility to assess the cost efficacy of interventions such as ablation, where Class 2b symptoms appear to be the appropriate treatment threshold.
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In that study, symptoms in class 2b identified patients with a health utility benefit of rhythm control.
“As symptoms in class 2b ('troubling' symptoms) identified patients with a health utility benefit of rhythm control in that study”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [199]
A modification was proposed in 2014, subdividing EHRA class 2 into mild (2a) or moderate (2b) impact.
“A modification was proposed in 2014, subdividing EHRA class 2 into mild (2a) or moderate (2b) impact.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [199]
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- Authors
- Wynn, G. J., Todd, D. M., Webber, M., Bonnett, L., McShane, J., Kirchhof, P., & Gupta, D.
- Affiliations
- Liverpool Heart and Chest Hospital (GB)
- University of Liverpool (GB)
- University of Münster (DE)
- Corresponding author
- Wynn, G. J.
- Venue
- Europace
- Publisher
- Oxford University Press (OUP)
- Published
- 2014-02-16
- Volume
- 16
- Issue
- 7
- Pages
- 965-972
- ISSN
- 1099-5129 (ISSN-L)
- 1532-2092
- PMC
- PMC4070972
- OpenAlex
- W2130595973
- Cited by
- 254
- References
- 29
- Citations by year
- 2026: 16 · 2025: 22 · 2024: 43 · 2023: 34 · 2022: 36 · 2021: 26 · 2020: 21 · 2019: 11 · 2018: 8 · 2017: 19 · 2016: 8 · 2015: 6 · 2014: 4
- FWCI
- 8.39
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by-nc
- Locations
- EP Europace (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- University of Birmingham Research Portal (University of Birmingham) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Keywords
- atrial fibrillation, symptom classification, quality of life, visual analogue scale, cost-effectiveness, patient-reported health status
- MeSH terms
- Aged, Atrial Fibrillation, Cost-Benefit Analysis, Female, Health Resources, Health Status, Health Status Indicators, Humans, Male, Middle Aged, Predictive Value of Tests, Prognosis, Prospective Studies, Quality of Life, Surveys and Questionnaires, Retrospective Studies, Reproducibility of Results, Discriminant Analysis, Health Care Costs
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