Clinical utility of the 4S-AF scheme in predicting progression of atrial fibrillation: data from the RACE V study

Abstract

Aims The recent 4S-AF (scheme proposed by the 2020 ESC AF guidelines to address stroke risk, symptom severity, severity of AF burden and substrate of AF to provide a structured phenotyping of AF patients in clinical practice to guide therapy and assess prognosis) scheme has been proposed as a structured scheme to characterize patients with atrial fibrillation (AF). We aimed to assess whether the 4S-AF scheme predicts AF progression in patients with self-terminating AF. Methods and results We analysed 341 patients with self-terminating AF included in the well-phenotyped Reappraisal of Atrial Fibrillation: Interaction between HyperCoagulability, Electrical remodelling, and Vascular Destabilization in the Progression of AF (RACE V) study. Patients had continuous monitoring with implantable loop recorders or pacemakers. AF progression was defined as progression to persistent or permanent AF or progression of self-terminating AF with >3% burden increase. Progression of AF was observed in 42 patients (12.3%, 5.9% per year). Patients were given a score based on the components of the 4S-AF scheme. Mean age was 65 [interquartile range (IQR) 58–71] years, 149 (44%) were women, 103 (49%) had heart failure, 276 (81%) had hypertension, and 38 (11%) had coronary artery disease. Median CHA2DS2-VASc (the CHA2DS2–VASc score assesses thromboembolic risk. C, congestive heart failure/left ventricular dysfunction; H, hypertension; A2, age ≥ 75 years; D, diabetes mellitus; S2, stroke/transient ischaemic attack/systemic embolism; V, vascular disease; A, age 65–74 years; Sc, sex category (female sex)) score was 2 (IQR 2–3), and median follow-up was 2.1 (1.5–2.6) years. The average score of the 4S-AF scheme was 4.6 ± 1.4. The score points from the 4S-AF scheme did not predict the risk of AF progression [odds ratio (OR) 1.1 95% CI 0.88–1.41, C-statistic 0.53]. However, excluding the symptoms domain, resulting in the 3S-AF (4S-AF scheme without the domain symptom severity, only including stroke risk, severity of AF burden and substrate of AF) scheme, predicted the risk of progression (OR 1.59 95% CI 1.15–2.27, C-statistic 0.62) even after adjusting for sex and age. Conclusions In self-terminating AF patients, the 4S-AF scheme does not predict AF progression. The 3S-AF scheme, excluding the symptom domain, may be a more appropriate score to predict AF progression. Trial registration numbers Clinicaltrials.gov NCT02726698 for RACE V

Clinical utility of the 4S-AF scheme in predicting recurrence of atrial fibrillation after radiofrequency catheter ablation

“…31 To evaluate atrial remodelling, we simply assessed LA enlargement by using Doppler ultrasound, which may lead to the neglect of early atrial remodelling manifesting as atrial dysfunction. 22,32,33 Consequently, the total St domain score and Su domain score in the current analysis were lower than those in previous studies. For the Sy domain, the severity of symptoms was greater in the current population than those in the EORP-AF Long-Term General Registry and APHRS-AF Registry.…”

“…The number of comorbidities was calculated by following comorbidities: hypertension, HF, hypercholesterolaemia, DM, CAD, peripheral artery disease, obesity (BMI>30 kg/m 2 ), kidney dysfunction (eGFR<60ml/min/1.73m 2 ) and moderate or severe mitral valve regurgitation. [20][21][22][23][24][25][26] 4S-AF scheme score was the sum of each domain with a maximum score of 10 (St=1, Sy=2, Sb=2, and Su=5). 2S-AF scheme score was modified by eliminating the Sy and St domains of the 4S-AF scheme score.…”

“…24,25 Recently, an analysis of RACE V data indicated that the 3S-AF scheme modified by eliminating the Sy domain of 4S-AF scheme may predict AF progression in the subset of self-terminating AF patients. 22 Furthermore, the 4S-AF scheme has prognostic implications for all-cause mortality and is a pragmatic risk stratification tool for patients with new-onset atrial fibrillation after myocardial infarction. 23 Nonetheless, studies assessing and validating the clinical utility and prognostic capability of the scheme in AF patients after RFCA are limited in number.…”

“…Moreover, the tools available to assess AF episodes and burden, including 24-h Holter monitoring and 12-lead ECG, may lead to underestimation of AF recurrence compared with implanted or continuous rhythm monitoring devices. 22,43 The 4S-AF scheme is a dynamic score, but we only assessed it at baseline and had limited follow-up data for periodic reassessment. Furthermore, there is some overlap between the four domains.…”

Women have less progression of paroxysmal atrial fibrillation: data from the RACE V study

“…As described previously, AF progression was defined as (1) the development of persistent or permanent AF during follow-up or (2) an increase of >3% AF burden over the first 6 months or total follow-up. 18 The 3% cutoff has been published previously, and details concerning the 3% cut-off for AF burden can be found in the paper by Nguyen et al [19][20][21] The duration of monitoring for the current analysis lasted until 1 May 2020, until the last available rhythm monitoring for patients who died after >1 year of continuous rhythm monitoring or until the date of PVI in case of a successful PVI.…”