Clinical Implications of Brief Device-Detected Atrial Tachyarrhythmias in a Cardiac Rhythm Management Device Population

Swiryn, Steven; Orlov, Michael V.; Benditt, David G.; DiMarco, John P.; Lloyd‐Jones, Donald M.; Karst, Edward; Qu, Fujian; Slawsky, Mara; Turkel, Melanie; Waldo, Albert L.

doi:10.1161/circulationaha.115.020252

Cited by 146 publications

(78 citation statements)

References 26 publications

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“…(47) In summary, despite subtle differences in design, all studies presently confirm that device-detected AF positively correlates with thromboembolic stroke, especially in patients with additional stroke risk factors (Table 1). (7,25,32,33,35,41,46) Clinical risk prediction scores, such as CHADS2, have been studied in this population and demonstrate value in supporting clinical decisions. (33,35) Uncertainty still exists regarding the exact burden of AF that portends the highest risk, yet a minimum threshold associated with clinically events may be in the range of 5 or 6 minutes.…”

Section: Resultsmentioning

confidence: 99%

“…(33,35) Uncertainty still exists regarding the exact burden of AF that portends the highest risk, yet a minimum threshold associated with clinically events may be in the range of 5 or 6 minutes. (7,25,33,35,41) The detection of shorter episodes should not be ignored as these herald a risk for developing a more significant AF burden over time and further study is required to identify stroke risk associated with these events. (41) It is also striking that the majority of AF appears not to be linked with thromboembolic events in a temporal manner, suggesting that atrial arrhythmias are markers of a propensity towards stroke as opposed to a direct etiology of left atrial thrombus.…”

Section: Resultsmentioning

confidence: 99%

“…Longer episodes were associated with a hazard ratio of 1.5 (p=0.03) for stroke or TIA and 1.7 (p<0.001) for the composite outcome. (41) These results suggest that very brief AHREs may not be clinically significant in isolation but, given a propensity for these patients to have longer episodes over time, close surveillance remains important. Furthermore, whether multiple shorter events are clinically equivalent to a single longer event of a similar cumulative duration and whether events longer than 20 seconds but less than 5 minutes in duration are clinically significant when compared to no events has yet to be determined.…”

Section: Risk Stratification In Patients With Device-detected Atrial mentioning

confidence: 91%

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Approach to device-detected subclinical atrial fibrillation

Zyl

McLeod²,

Gersh³

2017

SAHJ

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INTRODUCTIONCardiac implantable electronic devices (CIEDs) are becoming more and more common due to an aging global population and expanded criteria for implantation. During 2009, over 1.3 million new or replaced implantable cardiac devices were implanted worldwide, with around a quarter of these occurring in the United States (US) alone.(1,2) South Africa has experienced substantial growth with an almost 25% rise in CIEDs implanted between 2005 and 2009, as opposed to only 8% in the US.(1) In addition, there is a greater availability of external surface monitoring and implantable loop recorders (ILR). Out of this vast increase in continuous arrhythmia monitoring arises the challenge of how to approach the abundance of data that identifies subclinical arrhythmia, and germane to this discussion, atrial fibrillation (AF).As the most pervasive sustained arrhythmia encountered in clinical practice, AF has risen in age-adjusted incidence over the last half century -a trend which may be plateauing over the last decade.(3,4) After age 40 the lifetime risk of developing AF is almost 1 in 4.(2) As many as 40% of patients are entirely asymptomatic -also termed subclinical AF -and the arrhythmia may only come to the attention of the patient and provider as an incidental finding.(5) Population screening of those over 65 years of age would detect subclinical AF in an estimated 1.4% of patients -of whom, more than two thirds would be at high risk for stroke based on clinical risk prediction models.(6) AF shares many risk factors -including age, male gender, heart failure and coronary disease -with indications for a permanent pacemaker or implantable cardioverter defibrillator (ICD) and, as such, the detection of clinically silent paroxysms of AF by device interrogation is not uncommon. In patients with CIEDs placed for unrelated indications, without a prior history of permanent AF, 43% had 5 minutes or more of AF detected over 2 years of follow-up in a pooled analysis of 5 large prospective trials (n=10 016).(7) Therefore, adoption of a strategy for dealing with device-detected subclinical AF is vital for clinicians.In the midst of several studies which demonstrate the con-

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Risk Stratification In Patients With Device-detected Atrial mentioning

confidence: 91%

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Approach to device-detected subclinical atrial fibrillation

Zyl

McLeod²,

Gersh³

2017

SAHJ

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“…32 Several studies have taken advantage of these advances in continuous cardiac rhythm monitoring to investigate risk thresholds for AF burden and thromboembolic risk ( Table 1). [32][33][34][35][36][37][38][39][40][41] In a secondary analysis of the Mode Selection Trial (MOST), which followed 312 patients with dual-chamber pacemakers for a median of 27 months, atrial high-rate episodes (AHREs) lasting five minutes or more were associated with a significant increase in the risk of death or nonfatal stroke [hazard ratio (HR): 2.79, 95% confidence interval (CI): 1.51-5.15; p = 0.0011]. 33 A similar study using a prospective registry of 725 patients with dual-chamber pacemakers followed for a median of 22 months found that AF episodes lasting between five minutes and 24 hours in length were not associated with a significant increase in thromboembolic risk, but that episodes lasting more than 24 hours were independently associated with a threefold increase in the hazard of thromboembolic events (HR: 3.1, 95% CI: 1.1-10.5; p = 0.044).…”

mentioning

confidence: 99%

Tailored Anticoagulation for Thromboembolic Risk Reduction in Paroxysmal Atrial Fibrillation

Matos

Waks

Zimetbaum

2018

J Innov Cardiac Rhythm Manage

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“…And despite all of the above, there is the recognition that short AHREs are sometimes/often only a prelude to longer episodes, most recently reported by the RATEF Registry study (Registry of Atrial Tachycardia and Atrial Fibrillation Episodes). 7 Another puzzle is that asymptomatic episodes of SCAF detected by continuous monitoring in many, if not most, studies seem not to correlate closely with the timing of stroke. 4,[6][7][8]15 It may be that AF and thrombus formation might occur some days, weeks, or even months before the clot dislodges from the atrium and causes an embolic stroke, but it is difficult to incriminate AF as the stroke mechanism when the AF occurs only after the stroke.…”

mentioning

confidence: 99%