COMPARISON OF CLINICAL AND DEVICE-BASED CLASSIFICATION OF PAROXYSMAL/PERSISTENT ATRIAL FIBRILLATION AND OUTCOMES WITH ABLATION: INSIGHTS FROM CONTINUOUS IMPLANTABLE DEVICE MONITORING
CCC ePoster Library. Yao R. 10/26/19; 280513; 278
Ren Jie Robert Yao
Ren Jie Robert Yao
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Abstract
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BACKGROUND: Contemporary guidelines recommend that the clinical pattern of atrial fibrillation (AF) be assessed and classified based on episode duration, with AF defined as paroxysmal if the episode duration is < 7 days and persistent if >7 days. These clinically determined AF patterns have been used to characterize disease severity, define populations in trials, and form the basis of therapeutic recommendations.

METHODS AND RESULTS: A total of 346 patients aged >18 years with symptomatic, drug-refractory AF referred for ablation were enrolled. All patients received an implantable cardiac monitor (ICM) prior to ablation. At enrollment AF was classified by clinical assessment as low burden paroxysmal ( < 4 episodes over 6 months), high burden paroxysmal (>4 episodes over 6 months), or persistent (any episode >7d). Patients were re-classified using pre-ablation ICM device data. The agreement between clinical and device classification were assessed using Cohen's kappa. The relationship between the clinical classification of AF type and pre- and post-ablation 'AF burden' (as measured by the ICM) were assessed with ANOVA and linear trend. Freedom from recurrent AF/AFL/AT, by clinical or device classification, was assessed using log-rank test. There was little agreement between clinical and device classification (Cohen's kappa: 0.188, 95% CI: 0.102 to 0.275). The relationship between baseline AF burden and classification was strongest for device classification (slope for linear trend 21.30; 95%CI 18.89 to 23.72; P < 0.0001), vs. clinical classification (slope for linear trend 6.981; 95%CI 3.63 to 10.34; P < 0.0001). The relationship between post ablation AF burden and device classification was significant (slope for linear trend 2.57; 95%CI 1.24 to 3.90; P=0.0002) while clinical classification of AF had no relationship to post ablation AF burden (slope for linear trend 0.03; 95%CI -1.21 to 1.27; P=0.96). Device-derived AF classification was superior to clinical AF classification when examining the endpoint of time to first symptomatic or asymptomatic atrial tachyarrhythmia post atrial fibrillation ablation (log rank P=0.0006 vs. P=0.0971; Figure)

CONCLUSION: Classification of AF type based on pre-ablation continuous cardiac rhythm monitoring better predicted post ablation AF burden and freedom from recurrent AF. Despite the use of standardized definitions, clinical classification of AF type did not predict baseline AF burden, post ablation AF burden, or freedom from recurrent AF post ablation.
BACKGROUND: Contemporary guidelines recommend that the clinical pattern of atrial fibrillation (AF) be assessed and classified based on episode duration, with AF defined as paroxysmal if the episode duration is < 7 days and persistent if >7 days. These clinically determined AF patterns have been used to characterize disease severity, define populations in trials, and form the basis of therapeutic recommendations.

METHODS AND RESULTS: A total of 346 patients aged >18 years with symptomatic, drug-refractory AF referred for ablation were enrolled. All patients received an implantable cardiac monitor (ICM) prior to ablation. At enrollment AF was classified by clinical assessment as low burden paroxysmal ( < 4 episodes over 6 months), high burden paroxysmal (>4 episodes over 6 months), or persistent (any episode >7d). Patients were re-classified using pre-ablation ICM device data. The agreement between clinical and device classification were assessed using Cohen's kappa. The relationship between the clinical classification of AF type and pre- and post-ablation 'AF burden' (as measured by the ICM) were assessed with ANOVA and linear trend. Freedom from recurrent AF/AFL/AT, by clinical or device classification, was assessed using log-rank test. There was little agreement between clinical and device classification (Cohen's kappa: 0.188, 95% CI: 0.102 to 0.275). The relationship between baseline AF burden and classification was strongest for device classification (slope for linear trend 21.30; 95%CI 18.89 to 23.72; P < 0.0001), vs. clinical classification (slope for linear trend 6.981; 95%CI 3.63 to 10.34; P < 0.0001). The relationship between post ablation AF burden and device classification was significant (slope for linear trend 2.57; 95%CI 1.24 to 3.90; P=0.0002) while clinical classification of AF had no relationship to post ablation AF burden (slope for linear trend 0.03; 95%CI -1.21 to 1.27; P=0.96). Device-derived AF classification was superior to clinical AF classification when examining the endpoint of time to first symptomatic or asymptomatic atrial tachyarrhythmia post atrial fibrillation ablation (log rank P=0.0006 vs. P=0.0971; Figure)

CONCLUSION: Classification of AF type based on pre-ablation continuous cardiac rhythm monitoring better predicted post ablation AF burden and freedom from recurrent AF. Despite the use of standardized definitions, clinical classification of AF type did not predict baseline AF burden, post ablation AF burden, or freedom from recurrent AF post ablation.
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