Outcomes similar in silent or symptomatic AF

Major adverse outcomes of non-haemorrhagic stroke, death and major bleeding do not differ between patients with asymptomatic or symptomatic atrial fibrillation (AF).

The GARFIELD-AF study enrolled more than 52,000 patients of which 25% were asymptomatic and 75% had presented with symptoms such as palpitations or shortness of breath. The two groups had similar median CHA2DS2-VASc and HAS-BLED scores.

Approaches for stroke management were similar in both groups although a slightly larger proportion of asymptomatic patients received oral anticoagulants (OAC), with or without antiplatelets (AP), compared to symptomatic patients.

“Significant risk reductions in stroke/systemic embolism with OAC  use were demonstrated in both groups (asymptomatic: HR, 0.59; 95% CI, 0.43–0.82; symptomatic: HR, 0.78; 95% CI, 0.65–0.93), as well as in all-cause mortality (asymptomatic: HR, 0.69; 95% CI, 0.59-0.81; symptomatic: HR, 0.77; 95% CI, 0.71-0.85),” the study authors said.

“Both demonstrated an increased risk for major bleeding with OAC use (HR, 1.20; 95% CI, 0.85–1.68 and HR, 1.54; 95% CI, 1.24–1.90, respectively), although it only reached statistical significance in the symptomatic patients.”

The study, published in the American Journal of Medicine, highlighted the fact that asymptomatic and symptomatic subsets of patients responded equally well to oral anticoagulants was important, the investigators said.

“Unfortunately, large numbers of at-risk asymptomatic and symptomatic patients received no treatment, or AP [antiplatelet] only, despite the relative inefficacy of AP in preventing atrial fibrillation-related stroke – as has been observed by others,” they wrote.

“Given the likely similarity between asymptomatic patients with incidental atrial fibrillation clinical presentations, and those detected by opportunistic screening, our findings suggest that opportunistic atrial fibrillation screening programs might be worthwhile. An additional reason to justify screening is that asymptomatic atrial fibrillation presentations seem to respond similarly to OAC therapy as symptomatic atrial fibrillation.”

“These findings therefore support a likely benefit of screening across populations at risk for ‘silent atrial fibrillation’,” they added.

Professor David Brieger, lead author of the CSANZ guidelines for the diagnosis and management of AF told the limbic that  GARFIELD-AF provided a different dataset confirming what has previously been shown.

CSANZ guidelines on screening for silent AF said the benefits and harms of anticoagulant treatment have been assumed to be the same as for symptomatic AF.

The guidelines recommend opportunistic annual screening in patients aged ≥65 years by pulse palpation, followed by an ECG if irregular, or ECG rhythm strip using a handheld ECG.

Disclosure: The GARFIELD-AF registry is funded by an unrestricted research grant from Bayer AG (Berlin, Germany) awarded to the study sponsor the Thrombosis Research Institute (London, UK).

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