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Original research article
Atrial fibrillation patterns are associated with arrhythmia progression and clinical outcomes
  1. Renate B Schnabel1,2,
  2. Ladislav Pecen3,
  3. Daniel Engler1,2,
  4. Markus Lucerna4,
  5. Jean Marc Sellal5,
  6. Francisco M Ojeda1,2,
  7. Raffaele De Caterina6,7,
  8. Paulus Kirchhof8,9
  1. 1 University Heart Center Hamburg Eppendorf, Hamburg, Germany
  2. 2 German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck (RBS, DE, FMO), Berlin, Germany
  3. 3 Medical Faculty Pilsen of Charles University, Pilsen, Czech Republic
  4. 4 Daiichi Sankyo Europe, Munchen, Germany
  5. 5 Departement de Cardiologie, Centre Hospitalier Universitaire de Nancy, Nancy, France
  6. 6 G. d’Annunzio University, Chieti, Italy
  7. 7 Fondazione G. Monasterio, Pisa, Italy
  8. 8 University of Birmingham SWBH, Birmingham, UK
  9. 9 UHB NHS Trust, Birmingham, UK
  1. Correspondence to Dr Renate B Schnabel, Department of General and Interventional Cardiology, University Heart Centre, 20246 Hamburg, Germany; r.schnabel{at}


Objectives Determinants of atrial fibrillation (AF) patterns and of progression of earlier forms to permanent AF, and their relationship with outcome are still poorly understood.

Methods We examined AF patterns (paroxysmal, persistent and permanent), rate and predictors of AF progression, and outcomes in the PREFER (PREvention oF thromboembolic events-European Registry) in AF. The primary analysis was performed in the PREFER in AF prolongation dataset (n=3223 patients with AF with a complete 1-year follow-up, mean age 72±9 years, 40% women). Sensitivity analyses were performed using the PREFER in the AF study (n=6390 patients).

Results AF progressed to more persistent types in 506 patients (17%). Permanent AF was associated with development of heart failure at 1 year (OR 1.80, 95% CI 1.06 to 3.07, p=0.03) compared with paroxysmal AF, which was confirmed in the entire cohort. In multivariable-adjusted models, sinus rhythm at baseline, AF duration, cardioversion, hyperthyroidism, valvular heart disease, diabetes mellitus and heart failure were predictors of AF progression (area under the receiver operating characteristic curve 0.60, 95% CI 0.57 to 0.63). Results were similar when we restricted analyses to patients with AF duration <1 year. AF progression showed an association with coronary events over 1 year (OR 2.27, 95% CI 1.22 to 4.19, p=0.0074).

Conclusions Permanent AF at baseline was associated with incident heart failure. A substantial proportion of well-managed patients with AF showed AF progression over 1 year. AF progression itself was not strongly related to outcome and may indicate the need to refine the current classification of AF types to enhance clinical utility.

  • atrial fibrillation
  • epidemiology

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  • Contributors PK and ML contributed to acquisition of data, acquired funding and designed the research. RBS and DE made substantial contributions to conception and design. LP and FMO contributed to analysis and interpretation of data. RBS participated in drafting the article and JMS and RDC revised it critically for important intellectual content. All authors (RBS, LP, DE, ML, JMS, FMO, RDC, PK) gave final approval of the version to be submitted and any revised version.

  • Funding This project has received funding from Daiichi Sankyo Europe, the sponsor of the PREFER in AF and PREFER in AF prolongation registries. Further support came from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (grant agreement No 648131). This work was performed in the context of the Junior Research Alliance symAtrial project funded by the German Ministry of Research and Education (BMBF 01ZX1408A) e:Med –Systems Medicine program and German Centre for Cardiovascular Research (DZHK e.V.) (81Z1710103) (RBS). The PREFER in AF Registry has been funded by Daiichi Sankyo Europe. PK was partially supported by European Union (grant agreement no. 633196 [CATCH ME]) and British Heart Foundation (FS/13/43/30324).

  • Competing interests RDC reports that his institution received research grant support from Boehringer-Ingelheim, Bayer, Bristol-Myers Squibb/Pfizer and Roche; and honoraria for lectures and/or consulting from Boehringer-Ingelheim, Bayer and Bristol-Myers Squibb/Pfizer, Daiichi Sankyo, Lilly, AstraZeneca, Merck and Novartis. PK receives research support from European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (UK), and German Centre for Cardiovascular Research, from several drug and device companies active in AF, and has received honoraria from several such companies. PK is listed as inventor on two patents held by University of Birmingham (Atrial Fibrillation Therapy WO 2015140571, Markers for Atrial Fibrillation WO 2016012783).

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval Scientific Steering Committee of the PREFER in AF. Local Ethics Committees in Austria, Germany,Switzerland, Italy, Spain, France and UK provided their approval as required bynational regulations.

  • Provenance and peer review Not commissioned; externally peer reviewed.