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Rhythm- or rate-control strategies according to 4S-AF characterization scheme and long-term outcomes in atrial fibrillation patients: the FAMo (Fibrillazione Atriale in Modena) cohort

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Abstract

The 4S-AF scheme [Stroke risk, Symptom severity, Severity of atrial fibrillation (AF) burden, Substrate severity] was recently proposed to characterize AF patients. In this post hoc analysis we evaluated the agreement between the therapeutic strategy (rate or rhythm control, respectively), as suggested by the 4S-AF scheme, and the actual strategy followed in a patients cohort. Outcomes of interest were as follows: all-cause death, a composite of all-cause death/any thromboembolism/acute coronary syndrome, and a composite of all-cause death, any thrombotic/ischemic event, and major bleeding (net clinical outcome). We enrolled 615 patients: 60.5% male, median age 74 [interquartile range (IQR) 67–80] years; median CHA2DS2VASc 4 and median HAS-BLED 2. The 4S-AF score would have suggested a rhythm-control strategy in 351 (57.1%) patients while a rate control in 264 (42.9%). The strategy adopted was concordant with the 4S-AF suggestions in 342 (55.6%) cases, and non-concordant in 273 (44.4%). After a median follow-up of 941 days (IQR 365–1282), 113 (18.4%) patients died, 158 (25.7%) had an event of the composite endpoint. On adjusted Cox regression analysis, when 4S-AF score suggested rate control, disagreement with that suggestion was not associated with a worse outcome. When 4S-AF indicated rhythm control, disagreement was associated with a higher risk of all-cause death (HR 7.59; 95% CI 1.65–35.01), and of the composite outcome (HR 2.69; 95% CI 1.19–6.06). The 4S-AF scheme is a useful tool to comprehensively evaluate AF patients and aid the decision-making process. Disagreement with the rhythm control suggestion of the 4S-AF scheme was associated with adverse clinical outcomes.

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Author notes

  1. Gregory Y. H. Lip and Giuseppe Boriani joint senior authors.

Authors and Affiliations

  1. Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, 41124, Modena, Italy

    Vincenzo L. Malavasi, Marco Vitolo, Jacopo Colella, Francesca Montagnolo, Marta Mantovani & Giuseppe Boriani

  2. Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy

    Marco Vitolo

  3. Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK

    Marco Vitolo, Marco Proietti & Gregory Y. H. Lip

  4. Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy

    Marco Proietti

  5. Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy

    Marco Proietti

  6. School of Medicine, University of Belgrade, Belgrade, Serbia

    Tatjana S. Potpara

  7. Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia

    Tatjana S. Potpara

  8. Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

    Gregory Y. H. Lip

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TP is a consultant for Bayer and Pfizer (no fees). GB has received small speaker’s fees from Medtronic, Boston, Boehringer Ingelheim, and Bayer. GYHL is a consultant and speaker for Bayer/Janssen, BMS/Pfizer, Boehringer Ingelheim, and Daiichi-Sankyo (no fees are directly received personally). All the disclosures happened outside the submitted work. Other authors have no disclosures to declare.

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Malavasi, V.L., Vitolo, M., Colella, J. et al. Rhythm- or rate-control strategies according to 4S-AF characterization scheme and long-term outcomes in atrial fibrillation patients: the FAMo (Fibrillazione Atriale in Modena) cohort. Intern Emerg Med 17, 1001–1012 (2022). https://doi.org/10.1007/s11739-021-02890-x

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