Association between the presence or absence of symptoms and clinical outcomes in non-elderly patients with sustained atrial fibrillation without a history of heart failure: the Fushimi AF Registry

Background We previously reported that asymptomatic patients with paroxysmal atrial fibrillation (AF) had a higher incidence of all-cause mortality than symptomatic patients, whereas this difference was not observed in those with sustained (persistent or permanent) AF (Esato M, et al. Chest. 2017;152(6):1266-1275.). However, association between the presence of symptoms and clinical outcomes in non-elderly patients (<75 years) with sustained AF and no history of heart failure (HF) remains unclear. Purpose This study aims to evaluate the clinical characteristics and outcomes of patients with sustained AF, with or without symptoms. Methods From the Fushimi AF Registry, we identified sustained nonvalvular AF (NVAF) patients under 75 years of age with no history of HF. The clinical characteristics and outcomes of patients without symptoms were compared with those with symptoms. Clinical outcomes included all-cause mortality, major adverse cardiovascular and cerebrovascular events (MACCE), and major bleeding. MACCE was defined as a composite of cardiovascular death, myocardial infarction, stroke, or admission for HF. Results From the entire cohort (N=4,496), we identified 731 sustained NVAF patients under 75 years of age with no history of HF, including 541 patients without symptoms and 190 with symptoms. Patients without symptoms were more often male (77.5% vs. 67.9%, P<0.05), and had a higher history of major bleeding (3.9% vs. 0.5%, P<0.05), and a lower prevalence of chronic obstructive pulmonary disease (4.4% vs. 8.4%, P<0.05) than those with symptoms. Risk scores, including CHADS2, CHA2DS2-VASc, and HAS-BLED scores, and prescriptions at baseline were similar between patients with and without symptoms. The incidences (per patient-year) of all-cause mortality and MACCE were significantly higher in patients without symptoms than in those with symptoms (all-cause mortality: 2.7% vs. 1.7%, MACCE: 3.4% vs. 2.1%, all log-rank P<0.05). However, the incidence of major bleeding was comparable between the two groups (1.4% vs. 1.4%). Conclusion Non-elderly patients with sustained AF without symptoms had a worse prognosis than those with symptoms, despite no significant differences in baseline clinical characteristics between the two groups. This difference in prognosis may be attributed to variations in AF treatment based on the presence of symptoms.