Atrial high-rate episodes and stroke prevention

Abstract

While the benefit of oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation (AF) is well established, it is not known whether oral anticoagulation is indicated in patients with atrial high-rate episodes (AHRE) recorded on a cardiac implantable electronic device, sometimes also called subclinical AF, and lasting for at least 6 min in the absence of clinically diagnosed AF. Clinical evidence has shown that short episodes of rapid atrial tachycarrhythmias are often detected in patients presenting with stroke and transient ischaemic attack. Patients with AHRE have a higher likelihood of suffering from subsequent strokes, but their stroke rate seems lower than in patients with diagnosed AF, and not all AHRE episodes correspond to AF. The prognostic and pathological significance of AHRE is not yet fully understood. Clinical trials of OAC therapy are being conducted to determine whether therapeutic intervention would be beneficial to patients experiencing AHRE in terms of reducing the risk of stroke.

Rationale and design of the Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation (ARTESiA) trial

“…A recent review on stroke prevention in patients with subclinical AF suggests anticoagulating patients with subclinical AF if a history of ischemic stroke is present (20).…”

Are atrial high rate episodes (AHREs) a precursor to atrial fibrillation?

“…Subsequent intermittent 12 lead ECG or Holter monitoring has identified higher incidences of undiagnosed AF in stroke survivors [24,25]. The early detection of AHREs is thus clinically relevant considering that they have been shown to be associated with an elevated risk of thromboembolic events and death, such as 1.8%/year in the IMPACT trial, a multicentre randomised study of anticoagulant guided by remote rhythm monitoring in patients with implantable cardioverter-defibrillator and CRT-D devices [4,8,15,[26][27][28].…”

“…Irrespective of AF diagnosis, patients with devicedetected AHREs are at an elevated risk of stroke and may have unmet anticoagulation needs [8]. The incidence of AHRE detected by CIED can reach 50% but less than 25% of these patients are treated with an oral anticoagulant [9].…”

“…The incidence of AHRE detected by CIED can reach 50% but less than 25% of these patients are treated with an oral anticoagulant [9]. While the benefits of oral anticoagulation for stroke prevention in patients with clinical AF are well recognised, it is not known whether the same risk-benefit ratio exists for anticoagulation therapy in patients with AHREs [8]. Some studies do suggest that AHRE and AF differ regarding thromboembolism risk.…”

Prevalence of atrial high‐rate episodes and the risk factors in Indian patients with cardiac implantable electronic devices: Real‐world data

“…3,4,[7][8][9] Several risk factors, including aging, hypertension (HTN), diabetes, heart failure, vascular disease, valve disease, and others, have been associated with increased incidences of AF; however, the association of these risk factors for predicting AHRE or subclinical AF is not fully understood. [10][11][12] Hence, this study was performed to evaluate the prevalence and risk factors associated with the occurrence of AHRE in Indian patients with dual-chamber CIEDs.…”