Thromb Haemost 2021; 121(03): 270-278
DOI: 10.1055/s-0040-1716408
Review Article

The 4S-AF Scheme (Stroke Risk; Symptoms; Severity of Burden; Substrate): A Novel Approach to In-Depth Characterization (Rather than Classification) of Atrial Fibrillation

1  School of Medicine, University of Belgrade, Belgrade, Serbia
2  Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
1  School of Medicine, University of Belgrade, Belgrade, Serbia
3  Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
4  Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
Carina Blomstrom-Lundqvist
5  Department of Medical Science, Uppsala University, Uppsala, Sweden
Giuseppe Boriani
6  Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
Isabelle C. Van Gelder
7  University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
Hein Heidbuchel
8  University Hospital Antwerp, Antwerp University, Antwerp, Belgium
Gerhard Hindricks
9  Department of Cardiology and Electrophysiology, University Clinic of Cardiology, Heart Center Leipzig, Leipzig Heart Institute, Leipzig, Germany
Alan John Camm
10  St. George's University of London, London, United Kingdom
› Author Affiliations


Atrial fibrillation (AF) is a complex condition requiring holistic management with multiple treatment decisions about optimal thromboprophylaxis, symptom control (and prevention of AF progression), and identification and management of concomitant cardiovascular risk factors and comorbidity. Sometimes the information needed for treatment decisions is incomplete, as available classifications of AF mostly address a single domain of AF (or patient)-related characteristics. The most widely used classification of AF based on AF episode duration and temporal patterns (that is, the classification to first-diagnosed, paroxysmal, persistent/long-standing persistent, and permanent AF) has contributed to a better understanding of AF prevention and treatment but its limitations and the need for a multidimensional AF classification have been recognized as more complex treatment options became available. We propose a paradigm shift from classification toward a structured characterization of AF, addressing specific domains having treatment and prognostic implications to become a standard in clinical practice, thus aiming to streamline the assessment of AF patients at all health care levels facilitating communication among physicians, treatment decision-making, and optimal risk evaluation and management of AF patients. Specifically, we propose the 4S-AF structured pathophysiology-based characterization (rather than classification) scheme that includes four AF- and patient-related domains—Stroke risk, Symptoms, Severity of AF burden, and Substrate severity—and provide a hypothetical model for the use of 4S-AF characterization scheme to aid treatment decision making concerning the management of patients with AF in clinical practice.

* The editorial process for this paper was fully handled by Prof Christian Weber, Editor-in-Chief.

Publication History

Received: 16 August 2020

Accepted: 17 August 2020

Publication Date:
24 August 2020 (online)

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