Clinical outcomes in asymptomatic and symptomatic atrial fibrillation presentations in GARFIELD-AF: Implications for atrial fibrillation screening.

ABSTRACT Background : Asymptomatic atrial fibrillation is often detected incidentally. Prognosis and optimal therapy for asymptomatic compared to symptomatic atrial fibrillation is uncertain. This study compares clinical characteristics, treatment, and 2-year outcomes of asymptomatic and symptomatic atrial fibrillation presentations. Methods : GARFIELD-AF is a global, prospective, observational study of newly diagnosed atrial fibrillation with ≥1 stroke risk factors ( http://www.clinicaltrials.gov . Unique identifier: NCT01090362). Patients were characterized by atrial fibrillation-related symptoms at presentation and the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex (CHA2DS2-VASc) score. Two-year follow-up recorded anticoagulation patterns (vitamin K antagonist [VKAs], direct oral anticoagulants [DOACs], parenteral therapy) and outcomes (stroke/systemic embolism, all-cause mortality, and bleeding). Results : At presentation, 52,032 eligible patients, 25.4% were asymptomatic, and 74.6% symptomatic. Asymptomatic patients were slightly older (72 vs. 70 years), more often male (64.2% vs. 52.9%), and more frequently initiated on anticoagulation ± antiplatelets (AP) (69.4% vs. 66.0%). No difference in events (adjusted hazard ratios, 95% CI) for non-hemorrhagic stroke/systemic embolism (1.19, 0.97-1.45), all-cause mortality (1.06, 0.94-1.20), or bleeding (1.02, 0.87-1.19) was observed. Anticoagulation was associated with comparable reduction in non-hemorrhagic stroke/systemic embolism (0.59, 0.43–0.82 vs. 0.78, 0.65–0.93) and all-cause mortality (0.69, 0.59-0.81 vs. 0.77, 0.71-0.85) (asymptomatic vs symptomatic, respectively). Conclusions : Major outcomes do not differ between asymptomatic and symptomatic atrial fibrillation presentations and are comparably reduced by anticoagulation. Opportunistic screening-detected asymptomatic atrial fibrillation likely has the same prognosis as asymptomatic atrial fibrillation at presentation, and likely responds similarly to anticoagulation thrombo-prophylaxis.