A Comprehensive Evaluation of Rhythm Monitoring Strategies for the Detection of Atrial Fibrillation Recurrence

Abstract

Background-Intermittent rhythm monitoring (IRM) to detect atrial fibrillation (AF) recurrence is employed to evaluate the success of therapeutic interventions. In a large population of patients with continuous monitoring (CM), we investigated the sensitivity of various frequencies and durations of IRM strategies on the detection of AF recurrence, the dynamics behind AF recurrence detection, and we describe measures to evaluate temporal AF recurrence. Methods and Results-Rhythm histories of 647 patients (mean AF burden, 0.12Ϯ0.22; median, 0.014; with implantable CM devices were reconstructed and analyzed. With the use of computationally intensive simulation, the sensitivity of IRM of various frequencies and durations on the identification of AF recurrence was evaluated. Prolonged-duration IRM was superior to shorter IRM (PϽ0.0001). However, even with aggressive IRM strategies, AF recurrence was not detected in a great proportion of patients. The temporal AF burden aggregation (AF density) was directly related to IRM sensitivity (PϽ0.0001). Even at similar AF burdens, patients with high-density AF required higher-frequency or prolonged-duration IRM to achieve the same sensitivity as in low-density AF (PϽ0.0001). Patients with high-density, low-burden AF benefit the most from CM for detection of AF recurrence. Conclusions-IRM follow-up is significantly inferior to CM. IRM strategies will not identify AF recurrence in a great proportion of patients at risk. Key Words: atrial fibrillation Ⅲ atrial fibrillation arrhythmia Ⅲ rhythm monitoring Ⅲ rhythm recorders D etection of atrial fibrillation (AF) recurrence after therapeutic interventions has until now been based primarily on the results of intermittent ("snapshot") rhythm monitoring (IRM). This approach has significant limitations in terms of sensitivity because the monitoring period of these examinations is limited; however, the results of these examinations are used to draw inferences on the success of ablation procedures or pharmacological strategies. It has been shown that reliance on symptoms or office ECGs overestimates the success rate of the ablation procedures and will misclassify patients who have recurrence of paroxysmal AF as being in sinus rhythm. [1][2][3][4] The current consensus on AF monitoring recommends at least two 24-hour Holter monitor (HM) examinations annually for the detection of AF recurrence after ablation procedures, 5-7 which, however, has also been shown to underdetect AF recurrence and thus overestimate procedural success. 1,8 Reliable and accurate detection of AF recurrence is thus of special importance for the evaluation of pharmacological or ablation therapies as well as when decisions on changes in anticoagulation or antiarrhythmic therapy are to be made. Editorial see p 791 Clinical Perspective on p 814With the introduction of implantable, leadless rhythm recorders, continuous monitoring (CM) has been proposed Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the qui...

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