Skip to main content

Advertisement

SpringerLink
Log in

Clinical classification and the subclinical atrial fibrillation challenge: a position paper of the European Cardiac Arrhythmia Society

  • Reviews
  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Rahman F, Kwan GF, Benjamin EJ. Global epidemiology of atrial fibrillation. Nat Rev Cardiol. 2014;11:639–54.

    PubMed  Google Scholar 

  2. Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study. Circulation. 2014;129:837–47.

  3. Friberg L, Bergfeldt L. Atrial fibrillation prevalence revisited. Int Med. 2013;274:461–8.

  4. Wolf PA, Dawber TR, Thomas HE Jr, Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study. Neurology. 1978;28(10):973–7.

    CAS  PubMed  Google Scholar 

  5. Le Heuzey JY, Paziaud O, Piot O, Said MA, Copie X, Lavergne T. Cost of care distribution in atrial fibrillation patients: the COCAF study. Am Heart J. 2004;147:121–6.

    PubMed  Google Scholar 

  6. Ringborg A, Nieuwlat R, Lindgren P, Jonsson B, Fidan D, Maggioni AP, et al. Costs of atrial fibrillation in five European countries: results from the euro heart survey on atrial fibrillation. Europace. 2008;10:403–11.

    PubMed  Google Scholar 

  7. Reinhold T, Lindig C, Willich SN, Brüggenjürgen B. The costs of atrial fibrillation in patients with cardiovascular comorbidities--a longitudinal analysis of German health insurance data. Europace. 2011;13:1275–80.

    PubMed  Google Scholar 

  8. López-López JA, Sterne JAC, Thom HHZ, et al. Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. BMJ. 2017;359:j5058.

    PubMed  PubMed Central  Google Scholar 

  9. Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. 2012 HRS/EHRA/ECAS expert consensus document on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints and research trial design. J Interv Card Electrophysiol. 2012;23:171–267.

    Google Scholar 

  10. Bellet S. Atrial fibrillation (clinical manifestations). In: Clinical disorders of the heartbeat. Philadelphia: Lea and Fibiger; 1971. p. 223–33.

    Google Scholar 

  11. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. ESC scientific document group. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37:2893–962.

  12. Lévy S, Camm AJ, Saksena S, et al. International consensus on nomenclature and classification of atrial fibrillation. A collaborative project of the Working Group on Arrhythmias and the Working Group on Cardiac Pacing of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Europace. 2003;5:119–22 and J Cardiovasc Electrophysiol. 2003;14(4):443–5.

    PubMed  Google Scholar 

  13. Capucci A, Boriani G, Botto GL, Lenzi T, Rubino I, Falcone C, et al. Conversion of recent-onset atrial fibrillation by a single oral loading dose of propafenone or flecainide. Am J Cardiol. 1994;74:503–5.

  14. Levy S, Breithardt G, Campbell WF, et al. Atrial fibrillation: current knowledge and recommendations for management. Eur Heart J. 1998;19:1294–320.

    CAS  PubMed  Google Scholar 

  15. Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Developed in Collaboration with the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol. 2001;38(4):1266.

    Google Scholar 

  16. Fuster V, Rydén LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006;114(7):e257–354.

    PubMed  Google Scholar 

  17. Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al. ESC Committee for practice guidelines. Guidelines for the management of atrial fibrillation: the task force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace. 2010;12:1360–420.

  18. Wann LS, Curtis AB, January CT, et al. 2011 ACCF/AHA/HRS focus update on the management of patients with atrial fibrillation (updating the 2006 guideline). A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123:104–21.

    PubMed  Google Scholar 

  19. Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2018;20(1):e1–e160.

  20. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the national registry of atrial fibrillation. JAMA. 2001;285:2864–70.

    CAS  PubMed  Google Scholar 

  21. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel factor-based approach: the EuroHeart survey on atrial fibrillation. Chest. 2010;137:263–72.

    PubMed  Google Scholar 

  22. Ruff CT, Giugliano RP, Braunwald E, Murphy SA, Brown K, Jarolim P, et al. Cardiovascular biomarker score and clinical outcomes in patients with atrial fibrillation: a subanalysis of the ENGAGE AF-TIMI 48 randomized clinical trial. JAMA Cardiol. 2016;1(9):999–1006.

  23. Andrade JG, Macle L, Nattel S, Verma A, Cairns J, et al. Contemporary atrial fibrillation management – a comparison of the current AHA/ACC/HRS, CCS, and ESC guidelines. Can J Cardiol. 2017;33:965–76. https://doi.org/10.1016/j.cjca.2017.06.002.

    Article  PubMed  Google Scholar 

  24. Fauchier L, Philippart R, Clémenty A, et al. How to define valvular atrial fibrillation? Arch Cardiovasc Dis. 2015;108:530–9.

    PubMed  Google Scholar 

  25. Renda G, Ricci F, Giugliano RP, De Caterina R. Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and valvular heart disease. J Am Coll Cardiol. 2017;69:1363–71.

    PubMed  Google Scholar 

  26. Eikenboom JW, Connolly SJ, Brueckmann M, et al. RE-ALIGN Investigators. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med. 2013;369:1206–14.

    Google Scholar 

  27. Breithardt G. NOACs for stroke prevention in atrial fibrillation. Filling the gaps. J Am Coll Cardiol. 2017;69:1383–5.

    PubMed  Google Scholar 

  28. Lévy S, Maarek M, Coumel P, Guize L, Lekieffre J, Medvedowsky JL, et al. Characterization of different subsets of atrial fibrillation in general practice in France: the ALFA study. Circulation. 1999;99:3028–35.

    PubMed  Google Scholar 

  29. Wynn GJ, Todd DM, Webber M, Bonnett L, McShane J, Kirchhof P, et al. The European Heart Association symptom classification of atrial fibrillation: validation and improvement through a simple modification. Europace. 2014;16:965–72.

  30. Koci F, Torbes P, Mansour MC, Heist EK, Singh JP, Ellinor PT, et al. New classification scheme for atrial fibrillation symptom severity and burden. Am J Cardiol. 2014;114:260–5.

    PubMed  Google Scholar 

  31. Strickberger A, Ip J, Saksena S, Curry K, Bahnson T, Ziegler P. Relationship between atrial arrhythmias and symptoms. Heart Rhythm. 2005;2:125–31.

    PubMed  Google Scholar 

  32. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons. Circulation. 2019;140:e125–51.

    PubMed  Google Scholar 

  33. Andrade JG, Verma A, Mitchell BL, et al. For the CCS Atrial Fibrillation Guidelines Committee* 2018 focused update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2028;34:1371–92.

    Google Scholar 

  34. Flaker GC, Belew K, Beckman K, Vidaillet H, Kron J, Safford R, 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;149:657–63.

  35. Go AS, Reynolds K, Yang J, et al. Association of Burden of Atrial Fibrillation with Risk of ischemic stroke in adults with paroxysmal atrial fibrillation: The KP-RHYTHM Study. JAMA Cardiol. 2018;3:601–8.

    PubMed  PubMed Central  Google Scholar 

  36. Freeman B, Camm JA, Calkins H, Healy JS, Rosenqvist M, Wang J, et al. Screening for atrial fibrillation. A report of the AF-SCREEN international collaboration. Circulation. 2017;135:1851–67.

    Google Scholar 

  37. Tsang TS, Barnes ME, Pellikka PA, Gin K, Miyasaka Y, Seward JB, et al. Silent atrial fibrillation in Olmsted County: a community based study. Can J Cardiol. 2011;27:S122.

  38. Siontis K, Gersh B, Killian JM, et al. Typical, atypical and asymptomatic presentations of new-onset atrial fibrillation in the community: characteristics and prognostic implications. Heart Rhythm. 2016;0:1–7.

    Google Scholar 

  39. Rienstra M, Vermond RA, Crijns HJGM, Tijssen JGP, Van Gelder IC for the RACE Investigators. Asymptomatic persistent atrial fibrillation and outcome: results from the RACE study. Heart Rhythm. 2014;0:1–7.

    Google Scholar 

  40. Boriani G, Laroche C, Diemberger I, Fantecchi E, Popescu MI, Rasmussen LH, et al. Real-world' management and outcomes of patients with paroxysmal vs. non-paroxysmal atrial fibrillation in Europe: the EURObservational research Programme-Atrial Fibrillation (EORP-AF) general pilot registry. Europace. 2016;18:648–57.

  41. Potpara TS, Polovina MM, Marinkovic JM, Lip GY. A comparison of clinical characteristics and long-term prognosis in asymptomatic and symptomatic patients with first-diagnosed atrial fibrillation: the Belgrade atrial fibrillation study. Int J Cardiol. 2013;168:4744–9.

    PubMed  Google Scholar 

  42. Halcox JPJ, Wareham K, Cardew A, Gilmore M, Barry JP, Phillips C, et al. Assessment of remote heart rhythm sampling using the AliveCor heart monitor to screen for atrial fibrillation: the REHEARSE-AF study. Circulation. 2017;136(19):1784–94.

  43. Perez MV, Mahaffey KW, Hedlin H, Rumsfeld JS, Garcia A, Ferris T, et al. Large-scale assessment of a smartwatch to identify atrial fibrillation. N Engl J Med. 2019;381:1909–17.

  44. Lowres N, Olivier J, Chao T-F, Chen S-A, Chen Y, Diederichsen A, et al. Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals. PLoS Med. 2019;16(9):e1002903. https://doi.org/10.1371/journal.pmed.1002903.

  45. Jonas DE, Kahwati LC, Yun JDY, Middleton JC, Coker-Schwimmer M, Asher GN. Screening for atrial fibrillation with electrocardiography evidence report and systematic review for the US preventive services task force. JAMA. 2018;320:485–98.

    PubMed  Google Scholar 

  46. Mant J, Fitzmaurice DA, Hobbs FD, et al. Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative software: analysis of data from screening for atrial fibrillation in elderly (SAFE). BMJ. 2007;335:380.

    PubMed  PubMed Central  Google Scholar 

  47. Bogun F, Anh D, Kalahasty G, Wissner E, Bou Serhal C, Bazzi R, et al. Misdiagnosis of atrial fibrillation and its clinical consequences. Am J Med. 2004;117:636–42.

  48. Hindricks G, Pokushalov E, Urban L, Taborsky M, Kuck KH, Lebedev D, et al. On behalf of the XPECT Trial Investigators. Performance of a new leadless monitor in detecting and quantifying AF. Results of the XPECT trial. Circ Arrhythm Electrophysiol. 2010;3:141–7.

    PubMed  Google Scholar 

  49. Reiffel JA, Verma A, Kowey PR, Halperin JL, Gersh BJ, Wachter R, et al. REVEAL AF investigators. Incidence of previously undiagnosed atrial fibrillation using insertable cardiac monitors in a high-risk population: the REVEAL AF study. JAMA Cardiol. 2017;2:1120–7.

    PubMed  PubMed Central  Google Scholar 

  50. Healey JS, Alings M, Leong-Sit P, de Graaf J, Birnie D, Freericks M, et al. ASSERT II investigators. Subclinical atrial fibrillation in older patients. Circulation. 2017;136(14):1276–83.

    PubMed  Google Scholar 

  51. Saver JF. Cryptogenic stroke. N Engl J Med. 2016;374(21):2065–73.

    CAS  PubMed  Google Scholar 

  52. Schnabel RB, Haeusler KG, Healey JS, Freedman B, Boriani G, Brachmann J, et al. Searching for atrial fibrillation poststroke. A white paper of the AF-SCREEN International collaboration. Circulation. 2019;140:1834–50.

    PubMed  Google Scholar 

  53. Gladstone DJ, Spring M, Dorian P, Panzov V, Thorpe KE, Hall J, et al. EMBRACE investigators and coordinators. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370:2467–77.

    CAS  PubMed  Google Scholar 

  54. Brachmann J, Morillo CA, Tommaso S, et al. Uncovering atrial fibrillation beyond short-term monitoring in cryptogenic stroke patients. Three-year results from the cryptogenic stroke and underlying atrial fibrillation trial. Circ Arrhythm Electrophysiol. 2016;e003333:9.

    Google Scholar 

  55. Ziegler PD, Rogers JD, Ferreira SW, Nichols AJ, Richards M, Koehler JL, et al. Long-term detection of atrial fibrillation with insertable cardiac monitors in a real-world cryptogenic stroke population. Int J Cardiol. 2017;244:175–9.

    PubMed  Google Scholar 

  56. Israel C, Kitsiou A, Kalyani M, Deelawar S, Ejangue LE, Rogalewski A, et al. Detection of atrial fibrillation in patients with embolic stroke of undetermined source by prolonged monitoring with implantable loop recorders. Thromb Haemost. 2017;117:1962–9.

    PubMed  Google Scholar 

  57. Hart RG, Veltkamp RC, Sheridan P, Sharma M, Kasner SE, Bangdiwala SI, et al. NAVIGATE ESUS investigators. Predictors of recurrent ischemic stroke in patients with embolic strokes of undetermined source and effects of rivaroxaban versus aspirin according to risk status: the NAVIGATE ESUS trial. J Stroke Cerebrovasc Dis. 2019;28(8):2273–9.

    PubMed  Google Scholar 

  58. Freedman B, Boriani G, Glotzer T, Healey JS, Kirchhof P, Potpara TS. Management of high rate episodes detected by cardiac implanted electronic devices. Nat Rev Cardiol. 2017;14:7016714.

    Google Scholar 

  59. Camm AJ, Simantirakis E, Goette A, Lip GY, Vardas P, Calvert M, et al. Atrial high-rate episodes and stroke prevention. Europace. 2017;19:169–79.

    PubMed  Google Scholar 

  60. Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD, Hilker C, et al. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol. 2009;2:474–80.

    PubMed  Google Scholar 

  61. Boriani G, Glotzer TV, Santini M, West TM, de Melis M, Sepsi M, et al. Device detected atrial fibrillation and risk for stroke; an analysis of >10,000 patients from the SOS AF project (stroke prevention on strategies based on atrial fibrillation information from implanted devices). Eur Heart J. 2014;35:508–16.

    PubMed  Google Scholar 

  62. Brambatti M, Connolly SJ, Gold MR, Morillo CA, Capucci A, Muto C, et al. Temporal relationship between subclinical atrial fibrillation and embolic events. Circulation. 2014;129:2094–9.

    PubMed  Google Scholar 

  63. Boriani G, Laroche C, Diemberger I, Fantecchi E, Popescu MI, Rasmussen LH, et al. Asymptomatic atrial fibrillation: clinical correlates, management, and outcomes in the EORP-AF Pilot General Registry. Am J Med. 2015;128:509.e2–18.e2.

    Google Scholar 

  64. Hohnloser S, Capucci A, Fain C, Gold MR, Van Gelder IC, Healey J, et al. Asymptomatic atrial fibrillation and stroke evaluation in pacemakers patients and the atrial fibrillation reduction atrial pacing trial (ASSERT). Am Heart J. 2006;152:442–7.

    PubMed  Google Scholar 

  65. Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, et al. ASSERT Investigators. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med. 2012;366:120–9.

    CAS  PubMed  Google Scholar 

  66. Gonzalez M, Keating RJ, Markowitz SM, Liu CF, Thomas G, Ip JE, et al. Newly detected high rate atrial episodes predict long-term mortality outcomes in patients with implanted pacemakers. Heart Rhythm. 2014;11:2214–21.

    PubMed  Google Scholar 

  67. Van Gelder IC, Healey JS, Crijns HJGM, Wang J, Hohnloser S, Gold MR, et al. Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT. Eur Heart J. 2017;38:1339–44.

    PubMed  Google Scholar 

  68. Capucci A, Santini M, Padeletti L, Gulizia M, Botto GL, Boriani G, et al. Italian AT500 registry investigators. Monitored atrial fibrillation duration predicts arterial embolic events in patients suffering from bradycardia and atrial fibrillation implanted with antitachycardia pacemakers. J Am Coll Cardiol. 2005;46:1913–20.

    PubMed  Google Scholar 

  69. Botto GL, Padeletti L, Santini M, Capucci A, Gulizia M, Zolezzi F. Presence and duration of atrial fibrillation detected by continuous monitoring. Crucial implications for the risk of thromboembolic events. J Cardiovasc Electrophysiol. 2009;20:241–8.

    PubMed  Google Scholar 

  70. Abe H. Detection of atrial tachyarrhythmias in an implantable monitoring device. J Arrhythmia. 2012;28:19–25.

    CAS  Google Scholar 

  71. Noseworthy PA, Kaufman ES, Chen LY, Chung MK, Elkind MSV, Joglar JA, et al. Subclinical and device-detected atrial fibrillation: pondering the knowledge gap: a scientific statement of the American Medical Association. Circulation. 2019;140:e944–63.

    PubMed  Google Scholar 

  72. Kaufman ES, Israel CW, Nair GM, Armaganijan L, Divakaramenon S, Mairesse GH, et al. ASSERT steering committee and investigators. Positive predictive value of device-detected atrial high-rate episodes at different rates and durations: an analysis from ASSERT. Heart Rhythm. 2012;9(8):1241–6.

    PubMed  Google Scholar 

  73. Kaplan RM, Koehler J, Ziegler PD, Sarkar S, Zweibel S, Passman RS. Stroke risk as a function of atrial fibrillation duration and CHA2DS2-VASc score. Circulation. 2019;140:1639–46.

    PubMed  Google Scholar 

  74. Sugihara C, Veasey R, Freemantle N, Podd S, Furniss S, Sulke N. The development over time in patients with permanent pacemakers: objective assessment with pacemaker diagnostics demonstrates distinct patterns of AF. Europace. 2015;17:864–70.

    PubMed  Google Scholar 

  75. Timmermans C, Levy S, Ayers G, et al. Spontaneous episodes of atrial fibrillation after implantation of the Metrix Atrioverter®: observations on treated and nontreated episodes. J Am Coll Cardiol. 2000;35:1428–33.

    CAS  PubMed  Google Scholar 

  76. Lubitz SA, Benjamin EJ, Ruskin JN, Fuster V, Patrick T. Challenges in the classification of AF. Nat Rev Cardiol. 2010;7:451–60.

    PubMed  PubMed Central  Google Scholar 

  77. Lubitz SA, Moser C, Sullinan L, Rienstra M, Fontes JT, Villalon ML, et al. Atrial fibrillation patterns and risks of subsequent stroke, heart failure and death in the community. J Am Heart Assoc. 2013;e000126:2.

    Google Scholar 

  78. Charitos EI, Puererfellner H, Glotzer TV, Ziegler PD. Clinical classifications of atrial fibrillation poorly reflect its temporal persistence: insights from 1,195 patients continuously monitored with implantable devices. J Am Coll Cardiol. 2014;63:2840–8.

    PubMed  Google Scholar 

  79. Bernstein RA, Di Lazzaro V, Rymer MM, Passman RS, Brachmann J, Morillo CA, et al. Infarct topography and detection of atrial fibrillation in cryptogenic stroke: results from the CRYSTAL AF. Cerebrovasc Dis. 2015;40:91–6.

    PubMed  Google Scholar 

  80. Perera KS, Vanassche T, Bosch J, Giruparajah M, Swaminathan B, Mattina KR, et al. Embolic strokes of undetermined source: prevalence and patient features in the ESUS Global Registry. Int J Stroke. 2016;11:526–33.

    PubMed  Google Scholar 

  81. Passman R, Leong-Sit P, Andrei AC, Huskin A, Tomson TT, Bernstein R, et al. Targeted anticoagulation for atrial fibrillation guided by continuous rhythm assessment with an insertable cardiac monitor: the rhythm evaluation for anticoagulation with continuous monitoring (REACT.COM) pilot study. J Cardiovasc Electrophysiol. 2016;27(3):264–70.

    PubMed  Google Scholar 

  82. Martin DT, Bersohn MM, Waldo AL, Wathen MS, Choucair WK, Lip GYH, et al. Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac synchronization devices. Eur Heart J. 2015;36:1660–8.

    PubMed  Google Scholar 

  83. Turakhia MP, Ziegler PD, Schmitt SK, Chang Y, Fan J, Than CT, et al. Atrial fibrillation burden and short-term risk of stroke: case-crossover analysis of continuously recorded heart rhythm from cardiac electronic implanted devices. Circ Arrhythm Electrophysiol. 2015;8:1040–7.

    PubMed  Google Scholar 

  84. Perino AC, Fan J, Askari M, Heidenreich PA, Keung E, Raitt MH, et al. Practice variation in anticoagulation prescription and outcomes after device-detected atrial fibrillation. Insights from the veteran health administration. Circulation. 2019;139:2502–12.

    PubMed  PubMed Central  Google Scholar 

  85. Kirchhof P, Blank BF, Calvert M, Camm J, Chlouverakis G, Diener HC, et al. Probing oral anticoagulation in patients with high rate episodes: rationale and design of the non-vitamin K antagonist oral anticoagulants in patients with atrial high rates episodes (NOAH-AFNET6) trial. Am Heart J. 2017;190:12–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  86. Mahajan R, Perera T, Elliot AD, Twomey DJ, Kumar S, Munwar DA, et al. Subclinical device-detected atrial fibrillation and stroke risk: a systematic review and meta-analysis. Eur Heart J. 2018;0:1–9.

    Google Scholar 

  87. Lopes RD, Alings M, Connolly SJ, Beresh H, Granger CB, Mazuecos JB, et al. Rationale and design of the Apixaban for the reduction of thrombo-embolism in patients with device-detected sub-clinical atrial fibrillation (ARTESiA) trial. Am Heart J. 2017;189:137–45.

    PubMed  Google Scholar 

  88. Svennberg E, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Mass screening for untreated atrial fibrillation: the STROKESTOP study. Circulation. 2015;131:2176–84. https://doi.org/10.1161/CIRCULATIONAHA.114.014343.

    PubMed  Google Scholar 

  89. Healey JS, Sandhu RK. Are we ready for mass screening to detect atrial fibrillation? Circulation. 2015;131:2167–8.

    PubMed  Google Scholar 

  90. Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, Meeder JG, Lenderink T, Widdershoven, et al. Early or delayed cardioversion in recent-onset atrial fibrillation. N Engl J Med. 2019;380(16):1499–1508 RACE 7 ACWAS Investigators. ClinicalTrials.gov NCT02248753.

  91. Rostagno C, Bacci F, Martelli M, Naldoni A, Bertini G, Gensini G. Clinical course of lone AF since first symptomatic arrhythmic episode. Am J Cardiol. 1995;76:837–9.

    CAS  PubMed  Google Scholar 

  92. Simantirakis EM, Papakonstantinou P, Kanoupakis E, Chlouverakis GI, Tzeis S, Vardas PE. Recurrence rate of atrial fibrillation after the first clinical episode: a prospective evaluation using continuous cardiac rhythm monitoring. Clin Cardiol. 2018;41:601–7.

    Google Scholar 

  93. Nabauer M, Gerth A, Limburg T, Schneider S, Oeff M, Kirchhof P, et al. The Registry of German competence network on atrial fibrillation: patient characteristics and initial management. Europace. 2009;11:423–43.

    PubMed  PubMed Central  Google Scholar 

  94. Danias PG, Caulfield TA, Weigner MJ, Silverman DI, Manning WJ. Likelihood of spontaneous cardioversion of atrial fibrillation to sinus rhythm. J Am Coll Cardiol. 1998;31:588–92. https://doi.org/10.1016/s0735-1097(97)00534-2.

    Article  CAS  PubMed  Google Scholar 

  95. Saksena S, Hettrick DA, Koehler JL, Grammatico A, Padeletti L. Progression of paroxysmal atrial fibrillation to persistent atrial fibrillation in patients with bradyarrhythmias. Am Heart J. 2007;154:884–92.

    PubMed  Google Scholar 

  96. Gold MR. Treatment of subclinical atrial fibrillation. Does one plus one always equal two? Circulation. 2018;137:217–8.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Marseille School of Medicine, Aix-Marseille University, Marseille, France

    Samuel Lévy

  2. Cardiology Division, G. B. Grassi Hospital, Via G. Passeroni 28, Ostia Lido, RM, Italy

    Luca Santini

  3. Arrhythmia and Elecrtrophysiology Center, IRCCS-MultiMedica Group, Via Milanese 300, 20099, Milan, Sesto San Giovanni, Italy

    Riccardo Cappato

  4. Ludwig Maximilians University, Munich, Germany

    Gerhard Steinbeck

  5. Department of Cardiology, Università Politecnica delle Marche, Ancona, Italy

    Alessandro Capucci

  6. Rutgers-Robert Wood Johnson Medical School, Piscataway, NJ, USA

    Sanjeev Saksena

Authors
  1. Samuel Lévy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Luca Santini
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Riccardo Cappato
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gerhard Steinbeck
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Alessandro Capucci
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sanjeev Saksena
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Samuel Lévy.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lévy, S., Santini, L., Cappato, R. et al. Clinical classification and the subclinical atrial fibrillation challenge: a position paper of the European Cardiac Arrhythmia Society. J Interv Card Electrophysiol 59, 495–507 (2020). https://doi.org/10.1007/s10840-020-00859-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-020-00859-y

Keywords

Search

Navigation