title: The European Heart Rhythm Association symptom classification for atrial fibrillation: validation and improvement through a simple modification.
abstract: OBJECTIVE
  To validate the European Heart Rhythm Association (EHRA) symptom classification in atrial fibrillation (AF) and test whether its discriminative ability could be improved by a simple modification.
  
  
  RESULTS
  We compared the EHRA classification with three quality of life (QoL) measures: the AF-specific Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) questionnaire; two components of the EQ-5D instrument, a health-related utility which can be used to calculate cost-effectiveness, and the visual analogue scale (VAS) which demonstrates patients' own assessment of health status. We then proposed a simple modification [modified EHRA (mEHRA)] to improve discrimination at the point where major treatment decisions are made. quality of life data and clinician-allocated EHRA class were prospectively collected on 362 patients with AF. A step-wise, negative association was seen between the EHRA class and both the AFEQT and the VAS scores. Health-related utility was only significantly different between Classes 2 and 3 (P < 0.001). We developed and validated the mEHRA score separating Class 2 (symptomatic AF not limiting daily activities), based on whether the patients were 'troubled by their AF' (Class 2b) or not (Class 2a). This produced two distinct groups with lower AFEQT and VAS scores and, importantly, both clinically and statistically significant lower health utility (Δutility 0.9, P = 0.01) in Class 2b than Class 2a.
  
  
  CONCLUSIONS
  Based on patients' own assessment of their health status and the disease-specific AFEQT, the EHRA score can be considered a useful semi-quantitative classification. The mEHRA score has a clearer separation in health utility to assess the cost efficacy of interventions such as ablation, where Class 2b symptoms appear to be the appropriate treatment threshold.
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool and London, UK Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK gjw@doctors.org.uk.
authors.forename: Gareth J
authors.initials: GJ
authors.lastname: Wynn
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool and London, UK Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK.
authors.forename: Derick M
authors.initials: DM
authors.lastname: Todd
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool and London, UK Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK.
authors.forename: Matthew
authors.initials: M
authors.lastname: Webber
authors.affiliation: Department of Biostatistics, Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool L69 3GA, UK.
authors.forename: Laura
authors.initials: L
authors.lastname: Bonnett
authors.affiliation: Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK.
authors.forename: James
authors.initials: J
authors.lastname: McShane
authors.affiliation: University of Birmingham Centre for Cardiovascular Sciences and SWBH NHS trust, Birmingham B15 2TT, UK Department of Cardiology and Angiology, Hospital of the University of Münster, Münster, Germany.
authors.forename: Paulus
authors.initials: P
authors.lastname: Kirchhof
authors.affiliation: Institute of Cardiovascular Medicine and Science, Liverpool and London, UK Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK.
authors.forename: Dhiraj
authors.initials: D
authors.lastname: Gupta
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000145:classification / Q000175:diagnosis* / Q000191:economics / Q000503:physiopathology / Q000523:psychology / Q000628:therapy; D003362:Cost-Benefit Analysis; D016002:Discriminant Analysis; D005260:Female; D017048:Health Care Costs; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data; D006304:Health Status; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D011788:Quality of Life; D015203:Reproducibility of Results; D012189:Retrospective Studies; D011795:Surveys and Questionnaires
keywords: Atrial fibrillation; EHRA; Quality of life; Symptom score; Symptoms