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

Abstract

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

Article published online:
24 August 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Lewis T. Report Cxix. Auricular fibrillation: a common clinical condition. BMJ 1909; 2 (2552): 1528
  • 2 Lip G, Freedman B, De Caterina R, Potpara TS. Stroke prevention in atrial fibrillation: past, present and future. Comparing the guidelines and practical decision-making. Thromb Haemost 2017; 117 (07) 1230-1239
  • 3 Piccini JP, Fauchier L. Rhythm control in atrial fibrillation. Lancet 2016; 388 (10046): 829-840
  • 4 Cosio FG, Aliot E, Botto GL. et al. Delayed rhythm control of atrial fibrillation may be a cause of failure to prevent recurrences: reasons for change to active antiarrhythmic treatment at the time of the first detected episode. Europace 2008; 10 (01) 21-27
  • 5 Kotecha D, Chua WWL, Fabritz L. et al. European Society of Cardiology (ESC) Atrial Fibrillation Guidelines Taskforce, the CATCH ME consortium and the European Heart Rhythm Association (EHRA). European Society of Cardiology smartphone and tablet applications for patients with atrial fibrillation and their health care providers. Europace 2018; 20 (02) 225-233
  • 6 Kirchhof P, Benussi S, Kotecha D. et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18 (11) 1609-1678
  • 7 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 (02) e125-e151
  • 8 Andrade JG, Verma A, Mitchell LB. et al. CCS Atrial Fibrillation Guidelines Committee. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2018; 34 (11) 1371-1392
  • 9 Brieger D, Amerena J, Attia J. et al. NHFA CSANZ Atrial Fibrillation Guideline Working Group. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. Heart Lung Circ 2018; 27 (10) 1209-1266
  • 10 Gallagher MM, Camm J. Classification of atrial fibrillation. Am J Cardiol 1998; 82 (8A): 18N-28N
  • 11 Gallagher MM, Camm AJ. Classification of atrial fibrillation. Pacing Clin Electrophysiol 1997; 20 (06) 1603-1605
  • 12 Gallagher MM, Camm AJ. Long-term management of atrial fibrillation. Clin Cardiol 1997; 20 (04) 381-390
  • 13 Lévy S, Breithardt G, Campbell RW. et al. Working Group on Arrhythmias of the European Society of Cardiology. Atrial fibrillation: current knowledge and recommendations for management. Eur Heart J 1998; 19 (09) 1294-1320
  • 14 Lévy S, Novella P, Ricard P, Paganelli F. Paroxysmal atrial fibrillation: a need for classification. J Cardiovasc Electrophysiol 1995; 6 (01) 69-74
  • 15 Camm AJ, Al-Khatib SM, Calkins H. et al. A proposal for new clinical concepts in the management of atrial fibrillation. Am Heart J 2012; 164 (03) 292-302.e1
  • 16 Hammond-Haley M, Providencia R, Lambiase PD. Temporal pattern/episode duration-based classification of atrial fibrillation as paroxysmal vs. persistent: is it time to develop a more integrated prognostic score to optimize management?. Europace 2018; 20 (FI_3): f288-f298
  • 17 Wineinger NE, Barrett PM, Zhang Y. et al. Identification of paroxysmal atrial fibrillation subtypes in over 13,000 individuals. Heart Rhythm 2019; 16 (01) 26-30
  • 18 De With RR, Erküner Ö, Rienstra M. et al. RACE V Investigators. Temporal patterns and short-term progression of paroxysmal atrial fibrillation: data from RACE V. Europace 2020; 22 (08) 1162-1172
  • 19 Lubitz SA, Benjamin EJ, Ruskin JN, Fuster V, Ellinor PT. Challenges in the classification of atrial fibrillation. Nat Rev Cardiol 2010; 7 (08) 451-460
  • 20 Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol 2017; 14 (11) 627-628
  • 21 Chao TF, Lip GYH, Liu CJ. et al. Relationship of aging and incident comorbidities to stroke risk in patients with atrial fibrillation. J Am Coll Cardiol 2018; 71 (02) 122-132
  • 22 Chao TF, Lip GYH, Lin YJ. et al. Incident risk factors and major bleeding in patients with atrial fibrillation treated with oral anticoagulants: a comparison of baseline, follow-up and delta HAS-BLED scores with an approach focused on modifiable bleeding risk factors. Thromb Haemost 2018; 118 (04) 768-777
  • 23 Guo Y, Chen Y, Lane DA, Liu L, Wang Y, Lip GYH. Mobile health technology for atrial fibrillation management integrating decision support, education, and patient involvement: mAF app trial. Am J Med 2017; 130 (12) 1388-1396
  • 24 Diederichsen SZ, Haugan KJ, Brandes A. et al. Natural history of subclinical atrial fibrillation detected by implanted loop recorders. J Am Coll Cardiol 2019; 74 (22) 2771-2781
  • 25 Seligman WH, Das-Gupta Z, Jobi-Odeneye AO. et al. Development of an international standard set of outcome measures for patients with atrial fibrillation: a report of the International Consortium for Health Outcomes Measurement (ICHOM) atrial fibrillation working group. Eur Heart J 2020; 41 (10) 1132-1140
  • 26 Hijazi Z, Lindbäck J, Alexander JH. et al. ARISTOTLE and STABILITY Investigators. The ABC (age, biomarkers, clinical history) stroke risk score: a biomarker-based risk score for predicting stroke in atrial fibrillation. Eur Heart J 2016; 37 (20) 1582-1590
  • 27 Berg DD, Ruff CT, Jarolim P. et al. Performance of the ABC scores for assessing the risk of stroke or systemic embolism and bleeding in patients with atrial fibrillation in ENGAGE AF-TIMI 48. Circulation 2019; 139 (06) 760-771
  • 28 Ganesan AN, Chew DP, Hartshorne T. et al. The impact of atrial fibrillation type on the risk of thromboembolism, mortality, and bleeding: a systematic review and meta-analysis. Eur Heart J 2016; 37 (20) 1591-1602
  • 29 Al-Khatib SM, Thomas L, Wallentin L. et al. Outcomes of apixaban vs. warfarin by type and duration of atrial fibrillation: results from the ARISTOTLE trial. Eur Heart J 2013; 34 (31) 2464-2471
  • 30 Hart RG, Pearce LA, Rothbart RM, McAnulty JH, Asinger RW, Halperin JL. Stroke Prevention in Atrial Fibrillation Investigators. Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy. J Am Coll Cardiol 2000; 35 (01) 183-187
  • 31 Nieuwlaat R, Dinh T, Olsson SB. et al. Euro Heart Survey Investigators. Should we abandon the common practice of withholding oral anticoagulation in paroxysmal atrial fibrillation?. Eur Heart J 2008; 29 (07) 915-922
  • 32 Takabayashi K, Hamatani Y, Yamashita Y. et al. Incidence of stroke or systemic embolism in paroxysmal versus sustained atrial fibrillation: the Fushimi Atrial Fibrillation Registry. Stroke 2015; 46 (12) 3354-3361
  • 33 Mahajan R, Perera T, Elliott AD. et al. Subclinical device-detected atrial fibrillation and stroke risk: a systematic review and meta-analysis. Eur Heart J 2018; 39 (16) 1407-1415
  • 34 Wang SV, Rogers JR, Jin Y. et al. Stepped-wedge randomised trial to evaluate population health intervention designed to increase appropriate anticoagulation in patients with atrial fibrillation. BMJ Qual Saf 2019; 28 (10) 835-842
  • 35 Pastori D, Pignatelli P, Menichelli D, Violi F, Lip GYH. Integrated care management of patients with atrial fibrillation and risk of cardiovascular events: the ABC (Atrial fibrillation Better Care) Pathway in the ATHERO-AF Study Cohort. Mayo Clin Proc 2019; 94: 1261-1267
  • 36 Björkenheim A, Brandes A, Magnuson A. et al. Assessment of atrial fibrillation–specific symptoms before and 2 years after atrial fibrillation ablation: do patients and physicians differ in their perception of symptom relief?. JACC Clin Electrophysiol 2017; 3 (10) 1168-1176
  • 37 Potpara TS, Mihajlovic M, Zec N. et al. Self-reported treatment burden in patients with atrial fibrillation: Quantification, major determinants and implications for integrated holistic management of the arrhythmia. Europace 2020 (accepted)
  • 38 Blomström-Lundqvist C, Gizurarson S, Schwieler J. et al. Effect of catheter ablation vs antiarrhythmic medication on quality of life in patients with atrial fibrillation: the CAPTAF randomized clinical trial. JAMA 2019; 321 (11) 1059-1068
  • 39 Staerk L, Sherer JA, Ko D, Benjamin EJ, Helm RH. Atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes. Circ Res 2017; 120 (09) 1501-1517
  • 40 Staerk L, Wang B, Preis SR. et al. Lifetime risk of atrial fibrillation according to optimal, borderline, or elevated levels of risk factors: cohort study based on longitudinal data from the Framingham Heart Study. BMJ 2018; 361: k1453
  • 41 Brandes A, Smit MD, Nguyen BO, Rienstra M, Van Gelder IC. Risk factor management in atrial fibrillation. Arrhythm Electrophysiol Rev 2018; 7 (02) 118-127
  • 42 Donal E, Lip GY, Galderisi M. et al. EACVI/EHRA Expert Consensus Document on the role of multi-modality imaging for the evaluation of patients with atrial fibrillation. Eur Heart J Cardiovasc Imaging 2016; 17 (04) 355-383
  • 43 Hoit BD. Left atrial size and function: role in prognosis. J Am Coll Cardiol 2014; 63 (06) 493-505
  • 44 Khan MA, Yang EY, Zhan Y. et al. Association of left atrial volume index and all-cause mortality in patients referred for routine cardiovascular magnetic resonance: a multicenter study. J Cardiovasc Magn Reson 2019; 21 (01) 4
  • 45 Calkins H, Hindricks G, Cappato R. et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary. Europace 2018; 20 (01) 157-208
  • 46 Shade JK, Ali RL, Basile D. et al. Preprocedure application of machine learning and mechanistic simulations predicts likelihood of paroxysmal atrial fibrillation recurrence following pulmonary vein isolation. Circ Arrhythm Electrophysiol 2020; 13 (07) e008213
  • 47 Goette A, Kalman JM, Aguinaga L. et al. Document Reviewers. EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication. Europace 2016; 18 (10) 1455-1490
  • 48 Wijtvliet EPJP, Tieleman RG, van Gelder IC. et al. RACE 4 Investigators. Nurse-led vs. usual-care for atrial fibrillation. Eur Heart J 2020; 41 (05) 634-641
  • 49 Deng H, Bai Y, Shantsila A, Fauchier L, Potpara TS, Lip GYH. Clinical scores for outcomes of rhythm control or arrhythmia progression in patients with atrial fibrillation: a systematic review. Clin Res Cardiol 2017; 106 (10) 813-823
  • 50 Cosedis Nielsen J, Johannessen A, Raatikainen P. et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 2012; 367 (17) 1587-1595
  • 51 Morillo CA, Verma A, Connolly SJ. et al. RAAFT-2 Investigators. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. JAMA 2014; 311 (07) 692-700
  • 52 Wazni OM, Marrouche NF, Martin DO. et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. JAMA 2005; 293 (21) 2634-2640
  • 53 Pappone C, Augello G, Sala S. et al. A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF Study. J Am Coll Cardiol 2006; 48 (11) 2340-2347
  • 54 Jaïs P, Cauchemez B, Macle L. et al. Catheter ablation versus antiarrhythmic drugs for atrial fibrillation: the A4 study. Circulation 2008; 118 (24) 2498-2505
  • 55 Wilber DJ, Pappone C, Neuzil P. et al. ThermoCool AF Trial Investigators. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA 2010; 303 (04) 333-340
  • 56 Stabile G, Bertaglia E, Senatore G. et al. Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multi-centre, randomized, controlled study (Catheter Ablation For The Cure Of Atrial Fibrillation Study). Eur Heart J 2006; 27 (02) 216-221
  • 57 Oral H, Pappone C, Chugh A. et al. Circumferential pulmonary-vein ablation for chronic atrial fibrillation. N Engl J Med 2006; 354 (09) 934-941
  • 58 Packer DL, Kowal RC, Wheelan KR. et al. STOP AF Cryoablation Investigators. Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) pivotal trial. J Am Coll Cardiol 2013; 61 (16) 1713-1723
  • 59 Forleo GB, Mantica M, De Luca L. et al. Catheter ablation of atrial fibrillation in patients with diabetes mellitus type 2: results from a randomized study comparing pulmonary vein isolation versus antiarrhythmic drug therapy. J Cardiovasc Electrophysiol 2009; 20 (01) 22-28
  • 60 Mont L, Bisbal F, Hernández-Madrid A. et al. SARA investigators. Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study). Eur Heart J 2014; 35 (08) 501-507