Exploring the potential role of catheter ablation in patients with asymptomatic atrial fibrillation should we move away from symptom relief?

Although silent atrial fibrillation (AF) accounts for a significant proportion of patients with AF, asymptomatic patients have been excluded from AF ablation trials. This population presents unique challenges to disease management. Recent evidence suggests that patients with asymptomatic AF may have a different risk profile and even worse long-term outcomes compared to patients with symptomatic AF. For the same reasons they might be more prone to side-effects of antiarrhythmic drugs, including pro-arrhythmias. The poor correlation between symptoms and AF demonstrated in several studies should caution physicians against making clinical decisions depending on symptoms. Although current guidelines recommend AF ablation only in patients with symptoms, more attention should be paid to the AF burden and a rhythm control strategy has the potential to improve morbidity and mortality in AF patients. However, limited data exist regarding the use of catheter ablation for asymptomatic AF patients. As ablation techniques have improved, AF ablation has become more widespread and complication rate decreased. As a result, referrals of asymptomatic patients for catheter ablation of AF are on the rise. In this review we discuss the many unresolved questions concerning the role of the ablative approach in asymptomatic patients with AF.