Table 3.

AF Characteristics’ Association to Symptoms

Study	Samples	Design	Symptom Measurement	Assessment of cardiac rhythm	Findings	Limitations
Bhandari (1992), US(41)	N=113, 100% Paroxysmal, Age 50 (±15), 69% Female	Substudy of a randomized-controlled trial	Patient report	Transtelephonic EKG monitoring	Symptomatic calls significantly associated with documented AF, 91% sensitivity	Symptomatic AF was an inclusion criteria
Manganiello (2014), Italy(42)	N=113, 9% paroxysmal, 91% persistent, Age 64 (±20), 78% Male	Prospective cohort	Symptom diary	Insertable cardiac monitor	47% of patients had asymptomatic AF episodes, Significant association of symptoms to AF rhythm (P<0.01)	Symptomatic AF was inclusion criteria for the sample, all participants had undergone ablation, univariate analysis
Mehall, (2007), US(43)	N=50, Age 69, 74% Male	Prospective cohort	Manual activator when symptomatic episode perceived	Continuous home EKG monitoring	15% sensitivity, No significant association between symptoms and AF episode, 52% PPV	Long periods of AF were sometimes interrupted by EKG artifact, caused the monitor to record a new episode of AF
Quirino (2009), Italy(44)	N=102, 100% Paroxysmal AF, Age 73 (±7), 58% Male	Prospective Cohort	Symptom diary	Pacemaker	81% of device-stored episodes were asymptomatic, sensitivity was 19% and 21% PPV, duration of episodes was significantly related to symptomatic episode	Participants each had a pacemaker, symptoms were measured through self-report rather than a standardized tool
Sears (2005), US(27)	N=96, Age 62 (±12) 72% Male	Prospective cohort	ATSSS	Implantable cardioverter defibrillator	Insignificant association between symptoms and AF rhythm	All patients had an implantable cardioverter defibrillator
Silbauer (2009), UK(45)	N=79, 100% paroxysmal, Age 70 (±9), 57% Male	Prospective cohort substudy	Symptom diary	Pacemaker	Sensitivity of 13% and PPV of 63%, no significant difference in AF episode frequency between symptomatic and symptomatic follow-up periods, Heart rate and length of episodes significantly related to symptomatic episodes (p<0.001)	Symptomatic AF sample, relied on patients to complete symptom diaries, the participants each had a pacemaker
Strickberger (2005), US(46)	N=48, Age 76 (±10), 58% Male	Prospective randomized single-blind parallel study	Manual activator when symptomatic episode perceived, & symptom diary	Pacemaker	6% of AF episodes were symptomatic, 17% PPV, did not find a significant difference in ventricular rate and symptoms	Relied on patients to use the activator to identify symptomatic episodes over a 12-month period, sample consisted of patients with symptomatic bradycardia
Tondo (2014), Italy(47)	N=143, Age 59 (±9), 85% Male, 55% paroxysmal, 45% persistent	Prospective cohort	Manual activator when symptomatic episode perceived, & symptom diary	Implanted cardiac monitor	53% sensitivity, 89% PPV	Study was performed following catheter ablation
Patel (2014), US(31)	N=286, Age 62 (±13), 65% Male, 60% paroxysmal, 40% persistent	Prospective single-center cohort study	AFSS	Continuous looping monitor	No AF monitor characteristic was predictive of severe AF symptom burden, including HR and AF burden	Since symptoms were measured using the AFSS prior to the 7-day cardiac monitoring period, symptoms experienced when during the monitoring period were not captured
Patten (2006), Germany(34)	N=1033, Symptomatic paroxysmal	Longitudinal cohort	Self-monitoring event recorder system	Tele-EKG recorder	46% documented AF associated with specific symptoms, Symptoms were significantly correlated with heart rate (p<0.001), 37% perceived symptomatic AF episodes were genuine EKG-episodes, 69% of patients reported symptoms when in SR	Inclusion criteria was a history of symptomatic paroxysmal AF, the Tele-EKG monitoring did not collect data about the onset and duration of episodes because it a maximal EKG recording time of 1 minute
Verma (2013), Canada(48)	N=50, 80% paroxysmal, 10% persistent	Prospective cohort	Standardized symptoms diary	Continuous implanted cardiac monitoring	Symptoms had a 87% PPV, 69% of all AF episodes were asymptomatic	Inclusion criteria was first-time ablation procedure

Abbreviations: EKG, electrocardiogram; PPV, positive predictive value; SR, sinus rhythm; ATSSS, Atrial Tachyarrhythmia Symptom Severity Scale; AFSS, University of Toronto Atrial Fibrillation Severity Scale