Stages of AF

Q: There are how many stages of Atrial Fibrillation (AF)? - select one

A) Three

B) Four

Answer: B

In 2023, the American College of Cardiology/American Heart Association/American College of Clinical Pharmacy/Heart Rhythm Society and 2024 European Society of Cardiology (ESC) guidelines have been updated to recognize the "disease continuum" aspect of AF. This new classification is clinically significant, with distinct management strategies for each stage.

Stage 1: At risk for AF 

– This stage is identified by either modifiable or nonmodifiable risk factors for AF:

1. Modifiable – such as Obesity, lack of fitness, hypertension, sleep apnea, alcohol, diabetes mellitus

2. Non-modifiable risk factors – Genetics, male sex, and age

Stage 2: Pre-AF

– This stage is identified by structural or electrical findings or clinical conditions predisposing AF:

1. Structural findings – such as Atrial enlargement

2. Electrical findings – Frequent atrial ectopy, short bursts of atrial tachycardia, or atrial flutter

3. High-risk clinical conditions – Heart failure, valve disease, coronary artery disease, hypertrophic cardiomyopathy, neuromuscular disorders, or hyperthyroidism

Stage 3: AF

 – This stage is further categorized under four substages:

1. 3A: Paroxysmal AF – AF that is intermittent and terminates in ≤7 days from onset. 

2. 3B: Persistent AF – AF that is continuous for >7 days and often requires intervention. A patient who presents with persistent AF and later has paroxysmal AF with treatment are still considered to have persistent AF, as this designation is more helpful in defining their AF substrate and clinical outcomes. Chronic or Lone AF is no more used as a term.

3. 3C: Long-standing persistent AF – AF that is continuous for >12 months.

4. 3D: Successful AF ablation – Freedom from AF after catheter (percutaneous) or surgical intervention to eliminate AF.

Stage 4: Permanent AF

 – This term is used when the patient and clinician make a joint decision to stop further attempts to restore and/or maintain sinus rhythm (ie, rhythm control). This stage represents a therapeutic decision and an inherent attribute of AF. 

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References:

1. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1.

2. Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45:3314.

3. Wyse DG, Van Gelder IC, Ellinor PT, et al. Lone atrial fibrillation: does it exist? J Am Coll Cardiol 2014; 63:1715.