title: Symptom severity is associated with cardiovascular outcome in patients with permanent atrial fibrillation in the RACE II study.
abstract: OBJECTIVE
  Symptoms and symptom burden have a central place in diagnosis and management of atrial fibrillation (AF). The aim of the present study is to investigate whether severity of AF symptoms impacts prognosis in permanent AF.
  
  
  RESULTS
  We studied the relation between AF symptom severity [quantified with the Toronto AF Severity Scale (AFSS)] and cardiovascular outcome in patients included in the RACE II study. The primary endpoint was a composite of cardiovascular morbidity and mortality. Secondary outcome was cardiovascular hospitalizations. Of 614 permanent AF patients in RACE II, AFSS questionnaires were available in 558 patients (91%). Mean age was 68 ± 8 years. One hundred and seventy-four patients (31%) reported a low score (score 0-3; lowest tertile), 190 patients (34%) reported a moderate score (score 4-9; middle tertile), and 194 (35%) reported a high score (score 10-35; highest tertile). Patients with the most severe symptoms were more often women, had higher N-terminal prohormone of brain natriuretic peptide concentrations, and had more previous heart failure hospitalizations. Median follow-up was 3.0 (interquartile range 2.3-3.0) years. The primary endpoint occurred most frequently in the highest tertile of the AFSS [16 (9%), 19 (10%), 36 (19%), respectively, P = 0.01], being mainly driven by heart failure hospitalizations [4 (2%), 1 (1%), 16 (8%), respectively, P < 0.001]. After multivariable adjustment, higher AFSS scores were associated with the primary endpoint [hazard ratio 1.38 (1.15-1.66), P = 0.001], as well as with cardiovascular hospitalizations [hazard ratio 1.33 (1.14-1.54), P < 0.001].
  
  
  CONCLUSIONS
  In permanent AF, after multivariable adjustment, symptom severity is associated with cardiovascular outcome.
authors.affiliation: Department of Cardiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
authors.forename: Rob A
authors.initials: RA
authors.lastname: Vermond
authors.affiliation: Department of Cardiology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands.
authors.forename: Harry J G M
authors.initials: HJ
authors.lastname: Crijns
authors.affiliation: Department of Cardiology, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands.
authors.forename: Jan G P
authors.initials: JG
authors.lastname: Tijssen
authors.affiliation: Department of Cardiology, Amphia Hospital, 4800 RK Breda, The Netherlands.
authors.forename: A Marco
authors.initials: AM
authors.lastname: Alings
authors.affiliation: Department of Cardiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
authors.forename: Maarten P
authors.initials: MP
authors.lastname: Van den Berg
authors.affiliation: Trial Coordination Center, Department of Epidemiology, University Medical Center Groningen, 9700 RB Groningen, The Netherlands.
authors.forename: Hans L
authors.initials: HL
authors.lastname: Hillege
authors.affiliation: Department of Cardiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Van Veldhuisen
authors.affiliation: Department of Cardiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
authors.forename: Isabelle C
authors.initials: IC
authors.lastname: Van Gelder
authors.affiliation: Department of Cardiology, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands m.rienstra@umcg.nl.
authors.forename: Michiel
authors.initials: M
authors.lastname: Rienstra
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000401:mortality* / Q000503:physiopathology*; D015415:Biomarkers / Q000032:analysis; D002318:Cardiovascular Diseases / Q000401:mortality* / Q000503:physiopathology*; D002908:Chronic Disease; D015716:Electrocardiography, Ambulatory; D023381:Endpoint Determination; D005260:Female; D006339:Heart Rate / Q000187:drug effects; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D011379:Prognosis; D012307:Risk Factors; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires
chemical_list: D015415:Biomarkers
keywords: Atrial fibrillation; Prognosis; Rate control; Symptoms; Treatment