Major clinical outcomes in symptomatic vs. asymptomatic atrial fibrillation: a meta-analysis

Paschalis Karakasis; Konstantinos Pamporis; Konstantinos C Siontis; Panagiotis Theofilis; Athanasios Samaras; Dimitrios Patoulias; Panagiotis Stachteas; Efstratios Karagiannidis; George Stavropoulos; Apostolos Tzikas; George Kassimis; George Giannakoulas; Theodoros Karamitsos; Demosthenes G Katritsis; Nikolaos Fragakis

doi:10.1093/eurheartj/ehae694

Major clinical outcomes in symptomatic vs. asymptomatic atrial fibrillation: a meta-analysis

Eur Heart J. 2024 Oct 21:ehae694. doi: 10.1093/eurheartj/ehae694. Online ahead of print.

Authors

Paschalis Karakasis¹, Konstantinos Pamporis², Konstantinos C Siontis³, Panagiotis Theofilis⁴, Athanasios Samaras¹, Dimitrios Patoulias^{1

5}, Panagiotis Stachteas¹, Efstratios Karagiannidis¹, George Stavropoulos¹, Apostolos Tzikas^{1

6}, George Kassimis¹, George Giannakoulas⁷, Theodoros Karamitsos⁶, Demosthenes G Katritsis⁸, Nikolaos Fragakis¹

Affiliations

¹ Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece.
² Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
³ Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
⁴ First Cardiology Department, General Hospital of Athens 'Hippocratio', University of Athens Medical School, Athens, Greece.
⁵ Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki, Greece.
⁶ Department of Cardiology, European Interbalkan Medical Center, Thessaloniki, Greece.
⁷ First Department of Cardiology, Aristotle University Medical School, Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece.
⁸ Johns Hopkins, School of Medicine, Baltimore, MD, USA.

PMID: 39428997
DOI: 10.1093/eurheartj/ehae694

Abstract

Background and aims: Current guidelines suggest that asymptomatic atrial fibrillation (AF) is independently associated with increased risks of stroke and mortality compared with symptomatic AF. Considering that recent investigations have provided conflicting results, the present study aimed to evaluate the association between symptom status and clinical outcomes in patients with AF.

Methods: Medline, Cochrane Library, and Scopus were searched until 25 March 2024. Triple-independent study selection, data extraction and quality assessment were performed. Evidence was pooled using random-effects meta-analyses.

Results: Thirty-six studies (217 850 participants) were included. Based on the frequentist analysis, symptomatic individuals had no significant difference in the risk of all-cause mortality [hazard ratio (HR) .97, 95% confidence interval (CI) .80-1.17], cardiovascular mortality (HR 1.04, 95% CI .72-1.49), thromboembolism (HR 1.06, 95% CI .87-1.28), stroke (HR 1.06, 95% CI .84-1.34), hospitalization (HR 1.34, 95% CI .89-2.02), and myocardial infarction (HR .98, 95% CI .70-1.36), compared to the asymptomatic group. Symptomatic patients had a 33% increased risk of new-onset heart failure (HR 1.33, 95% CI 1.19-1.49) and a 30% lower risk of progression to permanent AF (HR .70, 95% CI .54-.89). The Bayesian analysis yielded comparable results, yet the association between symptom status and new-onset heart failure was not significant (HR 1.27, 95% credible interval .76-1.93; Bayes factor = 1.2). Symptomatic patients had higher odds of receiving antiarrhythmic drugs (odds ratio [OR] 1.64, 95% CI 1.33-2.03) and ablation therapy (OR 1.47, 95% CI 1.06-2.05) compared to asymptomatic cases.

Conclusions: The risk of major clinical outcomes did not differ between individuals with and without AF-related symptoms. Asymptomatic patients had a greater hazard of progression to permanent AF.

Keywords: Asymptomatic; Atrial fibrillation; EHRA score; Symptomatic; Symptoms.

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