Clinical utility and prognostic implications of the 4S‐AF scheme: Report from Asia Pacific Heart Rhythm Society Atrial Fibrillation Registry

Abstract

Background The 4S‐AF classification scheme comprises of four domains (stroke risk [St], symptoms [Sy], severity of atrial fibrillation (AF) burden [Sb] and substrate [Su]), which has been recommended in the 2020 ESC guidelines to characterize and evaluate patients with AF. Objectives We aimed to determine whether the 4S‐AF scheme would be useful for AF characterization and provides prognostic information in a large contemporary prospective Asian registry conducted by the Asia Pacific Heart Rhythm Society (APHRS). Methods Among 4666 patients enrolled in APHRS registry, 3586 of them whose data about left atrial (LA) dimension and European Heart Rhythm Association (EHRA) symptom score were available have constituted as the study population. The 4S‐AF score was calculated as the sum of each domain with a maximum score of 9. The clinical endpoint was defined as the 1‐year composite risk of any thromboembolic event, ischaemic stroke, heart failure, acute coronary syndrome, significant coronary artery disease requiring coronary intervention and all‐cause mortality. Results Based on the 4S‐AF domains, 86.7% were ‘non‐low risk’ for stroke; 94.3% had EHRA Class I‐II, 48.5% were newly diagnosed or paroxysmal AF; and only 8.4% had no cardiovascular risk factors or LA enlargement. The risk of clinical events was higher in patients who were ‘non‐low risk’ for stroke (aOR 2.175, 95% CI 1.060–4.461), with permanent AF (aOR 1.579, 95% CI 1.106–2.225) and increasing points for substrate (aORs 2.376–4.968 from score 2 to 4). When compared to the first tertile of 4S‐AF score (0–3 points), patients in the second tertile (4–5 points) had approximately 2.5‐fold increase in adverse events (OR 2.478, 95% CI 1.678–3.661, p < .001), while those in the third tertile (6–9 points), had a 3.5‐fold increase (OR 3.484, 95% CI 2.322–5.226, p < .001), both without significant differences between the 5 participating countries (p for interaction > .05). If all 4S‐AF domains were appropriately treated, this was associated with a lower risk of composite clinical outcomes (aOR 0.384, p < .001; p for interaction for different countries = .234). Conclusions Categorization according to the 4S‐AF scheme can be related to the risk of the composite adverse event rate in Asian AF patients, and appropriate treatments based on the 4S‐AF scheme resulted in better clinical outcomes. These observations support the characterization and management according to the 4S‐AF scheme in Asian patients.

Managing high-risk atrial fibrillation patients with multiple comorbidities

“…The APHRS AF registry also examined the clinical utility and prognostic implications of the 4S-AF scheme [7]. As expected, increasing adverse features by the 4S-AF scheme is associated with worse outcomes, consistent with prior analyses from Europe [8,9] and China [10].…”

“…In this situation, the anticoagulated AF patient may require concomitant antiplatelet therapy, which increases the risk of bleeding, including ICH. Current guidelines [7] recommend the use of a short period of triple therapy (OAC, aspirin, clopidogrel) for up to 2-4 weeks [in patients at particularly high bleeding risk, the aspirin may be dropped even earlier], followed by OAC plus a P2Y12 inhibitor (usually clopidogrel) for up to month 6-12. Beyond 12 months, OAC monotherapy is recommended.…”

“…Nonetheless, if the 4S-AF domains are appropriately treated, for example, for stroke risk, anticoagulation therapy reduces the composite clinical outcome, as does appropriate rate or rhythm control and risk factor management [7]. If all the 4S-AF domains were successfully and appropriately treated, there was a clear beneficial outcome (adjusted odds ratio 0.384, 95% CI 0.229-0.646) [7].…”

Impact of Catheter Ablation for Atrial Fibrillation on Quality of Life

“…This approach is feasible to characterize the arrhythmia and can guide the therapeutic strategy to improve clinical outcomes (any thromboembolic event, ischemic stroke, heart failure, acute coronary syndrome, significant coronary artery disease requiring coronary intervention and all-cause mortality) not only in the European but also in the Asian population [ 1 , 2 , 3 , 4 ].…”

The Report of Community-Based and Government-Endorsed Screening Program of Atrial Fibrillation in Taiwan

“…5,6 In the AF registry of Asia Pacific Heart Rhythm Society (APHRS), more than 60% of Asian AF patients were asymptomatic. 7 Therefore, how to detect AF via AF screening followed by the prescriptions of OACs is an important issue which has drawn much attention in these years 8 since more and more portable devices were available for electrocardiography (ECG) recording. 9 In the 2020 AF guidelines of European Society of Cardiology (ESC), opportunistic screening for AF by pulse taking or ECG rhythm strip is recommended in patients ≥65 years of age (Class I recommendation).…”