The European Heart Rhythm Association (EHRA) and the Council on Stroke of the European Society of Cardiology (ESC) have published a clinical consensus statement on AF burden. The lead author is Prof. Dr. Wolfram Döhner from Charité – Universitätsmedizin Berlin and the German Centre for Cardiovascular Research (DZHK). The aim of this publication is to establish an internationally harmonized, standardized, and clinically applicable definition of this increasingly relevant parameter—forming a foundation for improved diagnostics, therapy, and research.
What is AF burden – and why does it matter?
AF burden refers to the proportion of time a patient is in atrial fibrillation during a defined monitoring period. This is expressed as a percentage. In addition, where possible, the longest uninterrupted episode (LEAF) should also be reported. The consensus group deliberately moves away from the previously common categorical classification (e.g., paroxysmal, persistent). Studies have shown that the extent of AF has a significant impact on symptoms, prognosis, and therapeutic decisions.
To ensure comparability of AF burden measurements, the duration of monitoring must be specified. Reliable assessment of AF burden requires continuous or near-continuous ECG monitoring for at least 28 days. The shorter or more fragmented the ECG monitoring, the more likely the AF burden is overestimated, while AF prevalence is underestimated. Implantable monitors are considered the gold standard. Medically validated patch devices can also provide sufficient data under certain conditions. Symptom-triggered short-term ECGs, however, are not suitable for reliable AF burden assessment.
Clinical relevance in stroke, heart failure, and cognition
A higher AF burden is associated with an increased risk of stroke—especially for episodes lasting more than 24 hours. There are also correlations between AF burden and disease progression in heart failure, particularly in cases with preserved ejection fraction (HFpEF). Studies further suggest that high AF burden may negatively impact cognitive function. There is also evidence of reduced quality of life as AF burden increases.
The authors emphasize that there is no universal threshold at which AF burden becomes clinically relevant. Instead, thresholds must be validated for each specific condition, taking into account the individual risk profile and treatment goals. For stroke risk assessment, combining AF burden with the CHA₂DS₂-VASc score may serve as a useful basis.
A unified definition as a foundation for progress
"We need a reliable and comparable basis to better assess the clinical benefits of rhythm control, anticoagulation, or ablation in the future," says lead author Prof. Dr. Wolfram Döhner.
With this newly proposed definition, ESC and EHRA are laying an essential foundation: to enable study comparability, validation of disease-specific AF burden thresholds, risk-adapted clinical care, and targeted advancement of rhythm monitoring technologies and algorithms. This will not only support clinical decision-making but also contribute to the scientific and technological development of AF therapy.
Original publication:
Doehner, W. et al., Atrial fibrillation burden in clinical practice, research, and technology development: a clinical consensus statement of the European Society of Cardiology Council on Stroke and the European Heart Rhythm Association, EP Europace, March 2025
Scientific contact:
Univ.-Prof. Dr. Dr. med. Wolfram Döhner, Charité – Universitätsmedizin Berlin, Department of Cardiology, Wolfram.doehner(at)bih-charite.de
