Atrial fibrillation classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2] Anahita Deylamsalehi, M.D.[3]

Overview

Although several clinical classification plans and protocols have been proposed, none of them fully account for all aspects of atrial fibrillation. Previously the American Heart Association (AHA), American College of Cardiology (ACC), and the European Society of Cardiology (ESC) had proposed a classification system based on simplicity and clinical relevance. More recently, another classification has been proposed by a task force writing group which composed of experts representing seven organizations: the American College of Cardiology (ACC), the American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), the European Cardiac Arrhythmia Society (ECAS), the European Heart Rhythm Association (EHRA), the Society of Thoracic Surgeons (STS), and the Heart Rhythm Society (HRS). Still there are some shared definitions in almost all classification systems. Atrial fibrillation that terminates spontaneously or with intervention within 7 days of onset is considered a paroxysmal atrial fibrillation. On the other hand atrial fibrillation that lasts more than 7 days is named persistent atrial fibrillation. Long standing (or permanent) atrial fibrillation is referred to a atrial fibrillation that lasts for more than a year.

2014 AHA/ACC/HRS Classification

• Based on the duration of atrial fibrillation (AF) episodes, AHA/ACC/HRS published a simplified classification scheme given in the table below:

• Lone AF is a historical term which refers to atrial fibrillation in younger individuals (<60 years of age) without clinical or echocardiographic evidence of cardiopulmonary disease, hypertension, or diabetes mellitus. Because of its variable definitions, the term is potentially confusing and should not be used to guide therapeutic decisions.

Term	Definition
Paroxysmal AF	Atrial fibrillation that terminates spontaneously or with intervention within 7 d of onset. Episodes may recur with variable frequency.
Persistent AF	Continuous AF that is sustained >7 d.
Longstanding Persistent AF	Continuous AF of >12 mo duration.
Permanent AF	Permanent AF is used when there has been a joint decision by the patient and clinician to cease further attempts to restore and/or maintain sinus rhythm. Acceptance of AF represents a therapeutic attitude on the part of the patient and clinician rather than an inherent pathophysiological attribute of the AF. Acceptance of AF may change as symptoms, the efficacy of therapeutic interventions, and patient and clinician preferences evolve.
Nonvalvular AF	AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair.

AHA/ACC/ESC Classification

The classification that was proposed by the joint task force of AHA, ACC and ESC in 2006 is as follows:

AF Category	Defining Characteristics
First detected	Only one diagnosed episode.
Paroxysmal	Recurrent episodes that self-terminate in less than 7 days (most episodes are brief and last < 24 hours).
Persistent	Recurrent episodes that last more than 7 days and may require pharmacologic or electrical intervention.
Permanent	An ongoing long-term episode that lasts for more than a year despite attempts at cardioversion.

First Detected Atrial Fibrillation

Any patient with newly diagnosed AF is in this category, as the exact onset and chronicity of the disease is often uncertain. The patient may have been symptomatic or asymptomatic.

Recurrent Atrial Fibrillation

Two or more identified episodes of atrial fibrillation are named as recurrent form of atrial fibrillation. This is further classified into paroxysmal and persistent based on when the episode terminates without therapy.

Paroxysmal Atrial Fibrillation

• Atrial fibrillation is said to be paroxysmal when it terminates spontaneously within 7 days, most commonly within 24 hours.
• This type includes 20-30% of cases that have been diagnosed with atrial fibrillation.

Persistent Atrial Fibrillation

• Persistent atrial fibrillation is defined as episodes of atrial fibrillation of more than 7 days duration.
• Both the terms persistent and chronic are used if diagnosis of atrial fibrillation established for more than seven days.
• Differentiation of the paroxysmal type from chronic or established AF is based on the history of recurrent episodes and the duration of the current AF episode.
• Persistent type includes 20-30% of cases that have been diagnosed with atrial fibrillation.

Permanent Atrial Fibrillation

• Permanent atrial fibrillation is defined as atrial fibrillation that persists for more than a year. Cardioversion has either failed in these patients or has not yet been attempted.
• This type is the most common diagnosed type of atrial fibrillation (40-50%).

Lone Atrial Fibrillation (LAF)

Lone atrial fibrillation is defined as atrial fibrillation in the absence of clinical or echocardiographic findings of cardiopulmonary disease including hypertension. Patients in this group are young individuals (less than 60 years old).

AHA/ACC/APHRS/ECAS/EHRA/STS/HRS Classification

The newer classification proposed by the joint task force of AHA, ACC, APHRS, ECAS, EHRA, STS and HRS in 2012 is as follows

AF Category	Defining Characteristics
Atrial fibrillation episode	Atrial fibrillation with duration of at least 30 seconds or if less than 30 seconds, is present continuously throughout the ECG monitoring tracing. Sinus rhythm is documented in between AF episodes.
Paroxysmal atrial fibrillation	Recurrent episodes (≥two episodes) that self-terminate in less than 7 days. Episodes of AF of ≤48 hours duration that are terminated with electrical or pharmacologic cardioversion are also included.
Persistent atrial fibrillation	Recurrent episodes (≥two episodes) that last more than 7 days and may require pharmacologic or electrical intervention. Episodes of AF of ≥48 hours duration, but prior to 7 days, which are terminated with electrical or pharmacologic cardioversion are also included.
Longstanding persistent atrial fibrillation	Continuous atrial fibrillation of greater than 12 months duration.
Permanent atrial fibrillation	Atrial fibrillation which has been decided not to be restored or maintained in sinus rhythm by any means, including catheter or surgical ablation.

The term "chronic atrial fibrillation" has no standardized definition.

Atrial Fibrillation Episode

An atrial fibrillation episode is defined as AF which is documented by ECG monitoring and has a duration of at least 30 seconds, or if less than 30 seconds, is present continuously throughout the ECG monitoring tracing. The presence of subsequent episodes of AF requires that sinus rhythm be documented by ECG monitoring between AF episodes.

Paroxysmal Atrial Fibrillation

Paroxysmal atrial fibrillation is defined as recurrent episodes (≥two episodes) of AF that self-terminate in less than 7 days. Most episodes are brief and last < 24 hours. Episodes of AF of ≤48 hours duration that are terminated with electrical or pharmacologic cardioversion are also included.

Persistent Atrial Fibrillation

Recurrent episodes (≥two episodes) that last more than 7 days that may require pharmacologic or electrical intervention are called as persistent atrial fibrillation. Episodes of AF in which a decision is made to electrically or pharmacologically cardioversion after ≥48 hours of AF, but prior to 7 days, are also classified as persistent AF.

Longstanding Persistent Atrial Fibrillation

Longstanding persistent atrial fibrillation is a continuous atrial fibrillation of greater than 12 months duration. Continuous AF is an AF that is documented to be present on all ECG monitoring performed during a defined period of time.

Permanent Atrial Fibrillation

Permanent atrial fibrillation is an atrial fibrillation in patients in whom a decision has been made not to restore or maintain sinus rhythm by any means, including catheter or surgical ablation. If a patient who was previously classified as having permanent AF is to undergo catheter or surgical ablation, then AF should be reclassified.

References

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