Typical, atypical, and asymptomatic presentations of new-onset atrial fibrillation in the community: Characteristics and prognostic implications

Abstract

Background: The prognostic significance of the clinical presentation of atrial fibrillation (AF) is poorly defined.

Objective: The purpose of this study was to determine the frequency, associations, and prognostic impact of different clinical presentations of new-onset AF.

Methods: One thousand patients with incident AF in Olmsted County, Minnesota, were randomly selected (2000-2010). Patients with AF that was complicated at presentation (heart failure [n = 71], thromboembolism [n = 24]), provoked (n = 346), or unable to determine symptoms (n = 83) were excluded. In the remaining patients, characteristics and prognosis associated with different types of symptoms were examined.

Results: Among 476 patients, 193 had typical (palpitations), 122 had atypical (other non-palpitation symptoms), and 161 had asymptomatic AF presentation. Patients with typical presentation had lower CHA2DS2-VASc scores (mean 2.3 ± 2) compared to atypical and asymptomatic presentation (mean 3.2 ± 1.8 and 3.3 ± 1.9, respectively; P <.001). Fifty-nine cerebrovascular events and 149 deaths (n = 49 cardiovascular) were documented over median 5.6 and 6.0 years, respectively. Atypical and asymptomatic AF conferred higher risks of cerebrovascular events compared to typical AF after adjustment for CHA2DS2-VASc score and age (hazard ratio [HR] 3.51, 95% confidence interval [CI] 1.65-7.48, and HR 2.70, 95% CI 1.29-5.66, respectively), and associations remained statistically significant after further adjustments including comorbidities and warfarin use. Asymptomatic AF was associated with an increased risk of cardiovascular (HR 3.12, 95% CI 1.50-6.45) and all-cause mortality (HR 2.96, 95% CI 1.89-4.64) compared to typical AF after adjustment for CHA2DS2-VASc score and age.

Conclusion: The type of clinical presentation may have important implications for the prognosis of new-onset AF in the community.

Keywords: Atral fibrillation; Clinical presentation; Palpitations; Prognosis; Stroke.

Conflict of interest statement

Conflict of Interest Disclosures: None.

Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1. Estimated baseline stroke risk in the cohort: (A) distribution of CHA2DS2-VASc scores by type of atrial fibrillation presentation and (B) frequency of type of atrial fibrillation presentation among CHA2DS2-VASc score categories

Figure 2. Cumulative incidence curves of warfarin use treating death as a competing risk by type of atrial fibrillation presentation

Figure 3. 1-Cumulative incidence curves for (A) stroke or transient ischemic attack treating death as a competing risk and (B) cardiovascular death treating non-cardiovascular death as a competing risk, and Kaplan-Meier curves for (C) all-cause death by type of atrial fibrillation presentation