Letter regarding article, "Symptoms and functional status of patients with atrial fibrillation: state of the art and future research opportunities".

Letter Regarding Article, “Symptoms and Functional Status of Patients With Atrial Fibrillation: State of the Art and Future Research Opportunities” To the Editor: We read with great interest the article by Rienstra et al1 on symptoms and functional status of patients with atrial fibrillation (AF). In their article the authors reviewed in a very systematic and elegant way the current knowledge of a variety of symptoms related to AF. They discussed the relationship between the reduced functional capacity and loss of atrioventricular synchrony and stressed further need for more research enlightening interactions of AF and ventricular function. As highlighted in their diagram, AF symptoms have a very complex, often interacting pathophysiology. Although it is almost impossible to identify all contributing factors, we would like to point out the importance of left ventricular diastolic dysfunction (LVDD) that is missing in the authors’ scheme. In that respect, our group has shown previously the impact of LVDD on severity of AF symptoms defined by European Heart Rhythm Association2 score ranging from European Heart Rhythm Association I as no symptoms to European Heart Rhythm Association IV as disabling symptoms discontinuing daily activity. In this study, we have found prediagnosed LVDD to be related to more severe AF symptoms.3 Patients with LVDD were 6 times more likely to be admitted with moderate-severe AF symptoms than patients without LVDD. It can be assumed that, in patients with high ventricular filling pressure secondary to impaired diastolic function, the performance of the whole system is much more dependent on intact atrial function resulting in aggravated symptoms during AF. Our study can be seen as hypothesis generating because European Heart Rhythm Association classification describes severity grade more than individual symptoms and does not cover high variability of single AF episodes; in addition, the analysis was restricted to highly selected patient population. Nevertheless, we strongly believe that, in light of current reports revealing complex interactions between LVDD and AF, such as impact on ablation outcome and correlation with proarhythmogenic substrate,4 this entity will gain further clinical importance and will be given an adequate scientific prominence.