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New Appraisal of Atrial Fibrillation Burden and Stroke Prevention.

Atrial fibrillation (AF) quintuples the risk of stroke, and patients with stroke and AF are the most likely to be left dead or permanently disabled.1–4 More than 5 million people in the United States and >8 million people in the European Union were estimated to have AF in 2010.5–7 The lifetime risk of AF is high, with a quarter of 40-year-old patients expected to develop AF during the course of their lifetime.8 Because of aging populations, the prevalence of AF in the United Sates is expected to exceed 12 million by 2030, whereas in the European Union estimates 17.9 million cases by 2060.6,7 The risk of stroke can be stratified by various scores, including CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus [1 point], and previous stroke or transient ischemic attack [TIA; 2 points]) and the CHA2DS2-VASc score (congestive heart failure/left ventricular dysfunction, hypertension [1 point], age ≥75 years [2 points], diabetes mellitus [1 point], previous stroke or TIA [2 points], vascular disease, age 65–75 years, and female sex [1 point]).9,10 Multiple trials have demonstrated the efficacy of anticoagulation in reducing the risk of stroke by 65% to 80% in patients with clinically detected AF and other risk factors.10–13

AF burden can be defined as the time spent in AF per unit of time (day, week, month, etc). It is noteworthy that the burden of AF is not part of any risk stratification scoring system. In fact, current practice views AF as a dichotomous variable; one that is either present—whether paroxysmal, persistent, or permanent—or absent. Implicit in this perspective is an assumption that the burden AF is not relevant to stroke risk. This assumption is based on …