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

EP Europace Journal

22 November 2021
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ESC Journals

Abstract

AbstractAims

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.

Contributors

P Muda
P Muda

Author

Marco Proietti
Marco Proietti

Author

University of Milan Milan , Italy

Giuseppe Boriani
Giuseppe Boriani

Author

Modena Polyclinic Modena University Hospital Modena , Italy

D Wegink
D Wegink

Author

S Said
S Said

Author

Tatjana S Potpara
Tatjana S Potpara

Author

School of Medicine, Belgrade University Belgrade , Serbia

Gregory Y H Lip
Gregory Y H Lip

Author

University of Liverpool Liverpool , United Kingdom of Great Britain & Northern Ireland

H Crijns
H Crijns

Author

J Bouet
J Bouet

Author

J Taieb
J Taieb

Author

A Doucy
A Doucy

Author

P Janse
P Janse

Author

G-A Dan
G-A Dan

Author

A Furber
A Furber

Author

R Gevers
R Gevers

Author

J Dupuis
J Dupuis

Author

A Duygun
A Duygun

Author

F Marin
F Marin

Author

M Font
M Font

Author

B Rahel
B Rahel

Author

A Goda
A Goda

Author

J Abalea
J Abalea

Author

J Meeder
J Meeder

Author

A Vold
A Vold

Author

T Menez
T Menez

Author

G Range
G Range

Author

I Engset
I Engset

Author

S Riahi
S Riahi

Author

H Gorka
H Gorka

Author

P Muda
P Muda

Author

D Atar
D Atar

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C Laure

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E Koba

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O Piot

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A Sokal

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N Elbaz

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A Azhari

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I Mróz

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A Erglis

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