The European Heart Rhythm Association symptom classification for atrial fibrillation: validation and improvement through a simple modification

Abstract

Aims: 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.

Methods and 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.

Conclusion: 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.

Keywords: Atrial fibrillation; EHRA; Quality of life; Symptom score; Symptoms.

Figure 1

Quality of life (QoL) scores (mean ± standard deviation) by EHRA class.

Figure 2

Quality of life (QoL) scores (mean ± standard deviation) by mEHRA class. Classes 1, 3, and 4 are as for Figure 1. Class 2 has been split into Classes 2a (n = 43) and 2b (n = 47).

Figure 3

AFEQT sub-domain scores (mean ± standard deviation) by mEHRA class.