What is the role of the European Heart Rhythm Association (EHRA) symptom score in managing atrial fibrillation?

The Role of EHRA Symptom Score in Atrial Fibrillation Management

The EHRA symptom score is a critical tool for quantifying AF-related symptoms, guiding treatment decisions, and determining when to pursue rhythm control versus rate control strategies in patients with atrial fibrillation. 1

EHRA Symptom Score Classification

The European Heart Rhythm Association (EHRA) symptom score provides a standardized assessment of AF symptoms with four classes:

• EHRA Class I: No symptoms
• EHRA Class II: Mild symptoms
  • Class 2a: Mild symptoms not troubling to patient
  • Class 2b: Mild symptoms that are troubling to patient
• EHRA Class III: Severe symptoms affecting daily activity
• EHRA Class IV: Disabling symptoms with normal activity discontinued

The score only considers symptoms attributable to AF that reverse or reduce upon restoration of sinus rhythm or with effective rate control. 2

Clinical Application in AF Management

Initial Assessment

The EHRA score should be determined during initial clinical evaluation of patients with AF, along with:

• Estimation of stroke risk
• Search for conditions predisposing to AF
• Assessment for complications of the arrhythmia 2

Treatment Strategy Selection

The EHRA score directly influences treatment approach:

1. Rate Control Strategy:

   • Recommended as initial approach for elderly patients with minor symptoms (EHRA Class I) 2
   • Should be continued throughout rhythm control approach to ensure adequate ventricular rate control during AF recurrences

2. Rhythm Control Strategy:

   • Recommended for symptomatic patients (EHRA score >2) despite adequate rate control 2
   • Should be considered for patients with AF-related heart failure to improve symptoms
   • Should be considered as initial approach in young symptomatic patients where catheter ablation remains an option
   • Cardioversion is recommended for symptomatic patients (EHRA II-IV) with persistent AF 1

Treatment Monitoring

• The EHRA score should be documented at baseline and re-evaluated after treatment initiation
• Regular follow-up (recommended at 6 months after presentation, then annually) allows for treatment adjustments if symptom class changes 1

Clinical Significance and Validation

The EHRA score has been validated against quality of life measures and shows:

• Good internal consistency (Cronbach α>0.82)
• Strong reproducibility (intraclass correlation coefficient=0.93)
• Good correlation with health-related quality-of-life measures 3, 4

The modified EHRA (mEHRA) score improves discrimination by separating Class 2 into:

• Class 2a: Mild symptoms not troubling to patient
• Class 2b: Mild symptoms troubling to patient

This modification produces two distinct groups with clinically and statistically significant differences in health utility, helping to identify appropriate thresholds for interventions like ablation. 4

Common Pitfalls in Using EHRA Score

1. Overlooking asymptomatic patients: Patients with EHRA Class I (8.1% of AF patients) still require stroke prevention if CHA₂DS₂-VASc score indicates risk 5

2. Undertreatment of symptomatic patients: Failing to provide rhythm control for truly symptomatic patients (EHRA III-IV) 1

3. Static management: Not reassessing symptoms after treatment changes, leading to inadequate therapy adjustments 1

4. Ignoring comorbidities: The EHRA score should be interpreted alongside other risk factors and comorbidities

Emerging Perspectives

Recent consensus from AFNET/EHRA suggests rhythm management is evolving from therapy aimed primarily at improving symptoms to an integrated approach for preventing AF-related outcomes, especially in patients with recently diagnosed AF. This shift emphasizes the importance of the EHRA score not just for symptom assessment but as part of a comprehensive strategy to improve long-term outcomes. 6, 7