Temporal pattern/episode duration-based classification of atrial fibrillation as paroxysmal vs. persistent: is it time to develop a more integrated prognostic score to optimize management?

Atrial fibrillation (AF) is a clinically heterogeneous arrhythmia that is currently classified according to the variety of temporal rhythm based manifestations observed clinically, including 'first detected episode', 'paroxysmal', 'persistent', or 'permanent' AF. Despite being widely adopted by the most recent consensus guidelines, the utility of this classification system to stratify patients into distinct and clinically useful groups that have different outcomes including mortality, morbidity, specific cardiovascular outcomes, and quality of life (QoL), remains questionable. This is particularly true regarding the distinction between paroxysmal and persistent AF. Here, we demonstrate there is limited and conflicting evidence that this distinction is useful in predicting mortality, morbidity (including stroke and heart failure), symptom burden and QoL, although there is convincing evidence that patients with paroxysmal AF have favourable outcomes following electrical cardioversion and have better ablation procedural outcomes. Risk stratification schemes including the CHA2DS2VASc score are widely used to help clinicians stratify patients at high risk of stroke, whilst a number of newer, potentially superior, competitors have also recently been developed. A range of parameters including left atrial (LA) size, LA morphology, LA fibrosis assessed by magnetic resonance imaging (MRI) LA appendage morphology and LA function (assessed by echo) have all been recently suggested to identify higher risk patients and may, perhaps in combination with validated risk stratification scores and emerging genetic data, provide clinicians with the information necessary to more accurately stratify patients to ensure better outcomes of specific AF treatments and prevent adverse events.