Thirty-Second Gold Standard Definition of Atrial Fibrillation and Its Relationship With Subsequent Arrhythmia Patterns: Analysis of a Large Prospective Device Database

Abstract

Background: The Heart Rhythm Society consensus statement arbitrarily defines atrial fibrillation (AF) ablation failure as any episode ≥30 seconds. However, if brief AF events are not correlated to longer events, the rationale for this end point is questionable. We determined the impact of AF episode duration threshold on AF incidence and burden.

Methods: Patients with a pacemaker in a prospective registry with device-detected AF and follow-up >30 days were analyzed. AF patterns were calculated for various AF duration thresholds (30 s; 2 and 6 minutes; 3.8, 5.5, and 24 hours) selected based on published consensus statements, established evidence of stroke risk, and device capabilities. Freedom from AF postdevice implant at each AF episode duration threshold was assessed, as was overall AF burden.

Results: Among 615 patients with pacemaker (aged 72.0±11.8 years, 54.2% male, follow-up 3.7±2.2 years) with device-detected AF, 599 had ≥1 AF episode of ≥30 seconds duration (median, 22 episodes). At 12 months, freedom from AF was 25.5%, 30.1%, 34.6%, 52.6%, 56.5%, and 73.1% for duration thresholds of 30 seconds, 2 minutes, 6 minutes, 3.8 hours, 5.5 hours, and 24 hours, respectively. Of patients with a first episode of 30 seconds to 2 minutes, 35.8% were free from subsequent episode >2 minutes at 180 days. Median AF burden was significantly less for patients with first episodes between 30 seconds and 3.8 hours versus >3.8 hours (0.2% versus 9.5%, respectively; P<0.0001).

Conclusions: Small differences in AF episode duration definition can significantly affect the perceived incidence of AF and impact reported outcomes, including AF ablation success. An initial AF episode of 30 seconds does not predict clinically meaningful AF patterns.

Keywords: ablation; atrial fibrillation; consensus; stroke.