Clinical utility and prognostic implications of the novel 4S-AF scheme to characterize and evaluate patients with atrial fibrillation: a report from ESC-EHRA EORP-AF Long-Term General Registry
Wern Yew Ding, Marco Proietti, Giuseppe Boriani, Laurent Fauchier, Carina Blomström‐Lundqvist, Francisco Marı́n, Tatjana Potpara, Gregory Y.H. Lip, the ESC-EHRA EORP-AF Long-Term General Registry Investigators, G Boriani, G Y H Lip, L Tavazzi, Aldo P. Maggioni, G-A Dan, T Potpara, Michael Näbauer, Francisco Marı́n, Z Kalarus, L Fauchier, A Goda, G Mairesse, T Shalganov, L Antoniades, M Taborsky, S Riahi, P Muda, I García Bolao, O Piot, Michael Näbauer, K Etsadashvili, E Simantirakis, Moti Haim, Amirhossein Azhari, J Najafian, M Santini, E Mirrakhimov, K a Kulzida, A Erglis, Lidija Poposka, M Burg, Harry J. Crijns, Ö Erküner, D Atar, Radosław Lenarczyk, Mário Oliveira, D Shah, G-A Dan, E Serdechnaya, T Potpara, E Diker, G Y H Lip, D Lane, E Zëra, U Ekmekçiu, V Paparisto, M Tase, H Gjergo, J Dragoti, A Goda, M Ciutea, N. Ahadi, Ziad El Husseini, M. Raepers, J Leroy, P Haushan, A Jourdan, C Lepiece, L Desteghe, Johan Vijgen, Pieter Koopman, G Van Genechten, H Heidbuchel, Tim Boussy, M De Coninck, Hannelore Van Eeckhoutte, N Bouckaert, Alain Friart, J. Boreux, C Arend, P Evrard, L Stefan, E Hoffer, J. Herzet, M Massoz, C Celentano, Muriel Sprynger, Luc Piérard, P Melon, B Van Hauwaert, C Kuppens, Dirk Faes, Dirk van Lier, A. Van Dorpe, A. Gerardy, Olivier Deceuninck, Olivier Xhaët, Fabien Dormal, Elisabeth Ballant, Dominique Blommaert, D. Yakova
Abstract
AIMS: The 4S-AF classification scheme comprises of four domains: stroke risk (St), symptoms (Sy), severity of atrial fibrillation (AF) burden (Sb), and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and compare outcomes in AF patients according to the 4S-AF-led decision-making process. METHODS AND RESULTS: Atrial fibrillation patients from 250 centres across 27 European countries were included. A 4S-AF score was calculated as the sum of each domain with a maximum score of 9. Of 6321 patients, 8.4% had low (St), 47.5% EHRA I (Sy), 40.5% newly diagnosed or paroxysmal AF (Sb), and 5.1% no cardiovascular risk factors or left atrial enlargement (Su). Median follow-up was 24 months. Using multivariable Cox regression analysis, independent predictors of all-cause mortality were (St) [adjusted hazard ratio (aHR) 8.21, 95% confidence interval (CI): 2.60-25.9], (Sb) (aHR 1.21, 95% CI: 1.08-1.35), and (Su) (aHR 1.27, 95% CI: 1.14-1.41). For CV mortality and any thromboembolic event, only (Su) (aHR 1.73, 95% CI: 1.45-2.06) and (Sy) (aHR 1.29, 95% CI: 1.00-1.66) were statistically significant, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding. Higher 4S-AF score was related to a significant increase in all-cause mortality, CV mortality, any thromboembolic event, and ischaemic stroke but not major bleeding. Treatment of all 4S-AF domains was associated with an independent decrease in all-cause mortality (aHR 0.71, 95% CI: 0.55-0.92). For each 4S-AF domain left untreated, the risk of all-cause mortality increased substantially (aHR 1.35, 95% CI: 1.16-1.56). CONCLUSION: Implementation of the novel 4S-AF scheme is feasible, and treatment decisions based on this scheme improve mortality rates in AF.