Research Article: Recurrent event survival analysis predicts future risk of hospitalization in patients with paroxysmal and persistent atrial fibrillation

Date Published: June 7, 2019

Publisher: Public Library of Science

Author(s): Jakob Schroder, Olivier Bouaziz, Bue Ross Agner, Torben Martinussen, Per Lav Madsen, Dana Li, Ulrik Dixen, Tomohiko Ai.


In patients with paroxysmal atrial fibrillation (PAF) or persistent atrial fibrillation (PeAF) symptom burden and fear of hospital readmission are major causes of reduced quality of life. We attempted to develop a prediction model for future atrial fibrillation hospitalization (AFH) risk in PAF and PeAF patients including all previously experienced AFHs in the analysis, as opposed to time to first event.

Recurrent event survival analysis was used to model the impact of past AFHs on the risk of future AFHs. A recurrent event was defined as a hospitalization due to a new episode of AF. Death or progression to permanent AF were included as competing risks.

We enrolled 174 patients with PAF or PeAF, mean follow up duration was 1279 days, and 325 AFHs were observed. Median patient age was 63.0 (IQR 52.2–68.0), 29% had PAF, and 71% were male. Highly significant predictors of future AFH risk were PeAF (HR 3.20, CI 2.01–5.11) and number of past AFHs observed (HR for 1 event: 2.97, CI 2.04–4.32, HR for ≥2 events: 7.54, CI 5.47–10.40).

In PAF and PeAF patients, AF type and observed AFH frequency are highly significant predictors of future AFH risk. The developed model enables risk prediction in individual patients based on AFH history and baseline characteristics, utilizing all events experienced by the patient. This is the first time recurrent event survival analysis has been used in AF patients.

Partial Text

The choice of therapy in individual atrial fibrillation (AF) patients is largely dependent on AF subtype and present and predicted future symptom burden and morbidity, while the indication for anticoagulation treatment is closely related to stroke risk factors. Treatment options include rate controlling pharmacological agents, electrical and pharmacological cardioversion (CV), prophylactic antiarrhythmic medication (AAM) and catheter ablation procedures [1].

Using recurrent event survival analysis in a population of PAF and PeAF patients, our main findings were that (i) patients with PeAF generally had a significantly higher risk of future AFHs than those with PAF, (ii) in both PAF and PeAF patients, being hospitalized with AF symptoms is a major predictor of future AFHs, and (iii) the applied statistical model allows quantitative risk prediction for individual patients, taking into account both baseline characteristics and number of recurrent events in the time interval since the patient was last evaluated.




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