JACC in a Flash: "Lone" AF Never Really Alone

Sixty years ago, the term "lone AF"—indicating atrial fibrillation without demonstrative heart disease—was coined, but given our current understanding of the pathophysiology of AF, its multiple known etiologies, and new advanced imaging and diagnostic techniques, the concept no longer seems valid. In a recent white paper published in JACC, D. George Wyse, MD, PhD, from the University of Calgary, Alberta, and colleagues question whether this concept of "lone AF" actually exists.

The first problem with lone AF: no one can agree on a definition, and this inconsistency causes confusion in the literature. Current guidelines provide a vague definition of lone AF ("AF in younger adults with no clinical history or echocardiographic evidence of concomitant cardiovascular or pulmonary conditions"), the authors point out, but do not offer direction about how much or what kind, of imaging and other testing is necessary to exclude concomitant heart disease. Wyse et al. also refer to the reported prevalence of lone AF, which varies widely—ranging from 0.2% to 68% in various trials—depending on the definition used.

Multiple scientific and technical advances have been made that help identify the mechanisms through which various etiologies lead to AF in the decades since the term "lone AF" was coined; but the understanding remains incomplete at this time. Several structural and functional factors contribute to the development of AF, and many of patients without traditional heart disease likely develop AF as a result of these multiple influences, rather than a single cause. Notably, the authors' review of literature about lone AF found no mechanisms unique to lone AF.

"A consideration of our current state of knowledge about AF and the inconsistency in usage of the term leads to the logical proposal that the historical term 'lone AF' should be avoided," the authors concluded. Should a cardiologist suspect a case of lone AF in a patient, Wyse et al. recommend a thorough search for risk factors and cardiovascular disease. In the future, studies should aim to find optimal treatment of risk factors that may prevent or delay the development of AF, improve maintenance of sinus rhythm, and ultimately improve prognosis once AF appears.

Wyse DG, Van Gelder IC, Ellinor PT, et al. J Am Coll Cardiol. 2014 February 12. [Epub ahead of print]

Keywords: Heart Diseases, Prevalence, Prognosis, Risk Factors

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