Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT

Gelder, Isabelle C. Van; Healey, Jeff S.; Crijns, Harry J.G.M.; Wang, Jia; Hohnloser, Stefan H.; Gold, Michael R.; Capucci, Alessandro; Lau, Chu‐Pak; Morillo, Carlos A.; Hobbelt, Anne H; Rienstra, Michiel; Connolly, Stuart J.

doi:10.1093/eurheartj/ehx042

Cited by 498 publications

(353 citation statements)

References 30 publications

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“…Recent data suggests an excess stroke risk in patients with more than 24 hours of continuous AF even when controlling for other stroke risk factors. (34) We would recommend utilising clinical judgement to balance the risk of the risk of bleeding with initiation of systemic anticoagulation with the thromboembolism based on higher AF burden and presence of additional risk factors.…”

Section: Resultsmentioning

confidence: 99%

“…(7) Similarly, a recently published reanalysis of ASSERT data found that, even when controlling for other stroke risk factors (age, sex, BMI, heart failure, prior stroke, diabetes and arterial disease) a continuous AF burden of more than 24 hours was associated with increased risk of stroke or systemic embolism (hazard ratio 3.24, p=0.003) with no significant difference when comparing shorter durations to no AF. (34) Higher AF burden appears to be associated with higher risk of stroke, at least in part due to the finding that longer duration AHREs have a higher positive predictive for true AF. (28) Risk stratification using clinical risk prediction scores for patients with device-detected AF has been studied.…”

Section: Risk Stratification In Patients With Device-detected Atrialmentioning

confidence: 99%

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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: Risk Stratification In Patients With Device-detected Atrialmentioning

confidence: 99%

Approach to device-detected subclinical atrial fibrillation

Zyl

McLeod²,

Gersh³

2017

SAHJ

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“…The threshold for a significant increase of TE risk varied from 5 minutes to 24 hours. [17][18][19][44][45][46][47] It seems reasonable to speculate that the implications of AF burden may be different in patients with different baseline risks, in particular in patients with or without prior stroke. An interesting observation supporting the hypothesis of a multivariable model and the absence of a fixed threshold predictive of increased risk is suggested from a proof-of-concept study in which the risk of stroke or TE events was found to be not only a function of the time spent in AF, but also of the baseline characteristics of the patients.…”

Section: Af Burden and Risk Of Strokementioning

confidence: 99%

Detection and management of atrial fibrillation after cryptogenic stroke or embolic stroke of undetermined source

Sanna

Ziegler

Crea

2018

Clinical Cardiology

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Cryptogenic stroke (CS) and embolic stroke of unknown source (ESUS) represent a major challenge to healthcare systems worldwide. Atrial fibrillation (AF) is commonly found after CS or ESUS. Independent of the mechanism of the index CS or ESUS, detection of AF in these patients offers the opportunity to reduce the risk of stroke recurrence by prescribing an anticoagulant instead of aspirin. The detection of AF may be pursued with different monitoring strategies. Comparison of monitoring strategies should take into account that AF detection rates reported in published studies, and then pooled in meta-analyses, are not only a function of the monitoring strategy itself, but also depend on patient-related, device-related, and study design-related factors. Once AF is found, the decision to anticoagulate a patient should be made on the basis of AF burden and the baseline risk of the patient. Empirical anticoagulation in patients with ESUS and no evidence of AF is an intriguing but still-unproven strategy and therefore should not be adopted outside of randomized clinical trials.Each year, >790 000 people experience a new or recurrent stroke in the United States. 1 The cause of ischemic stroke remains undetermined after hospitalization in 10% to 40% of cases; this is often referred to as "cryptogenic" stroke (CS). 2 Differences in the definition and diagnostic workup contribute to this variable incidence in published series. To mitigate this limitation, the term "embolic stroke of undetermined source" (ESUS) has recently been proposed to identify those cases where the etiology of nonlacunar ischemic stroke remains elusive after a standardized diagnostic pathway. 3 The prevalence of ESUS was 16% to 32% in a recently published series. 4 Hence, even after a standardized comprehensive evaluation, the cause of ischemic stroke remains elusive in a significant proportion of patients, thus representing a major challenge for treatment selection. | STROKE RECURRENCE IN PATIENTS WITH PRIOR CS AND ESUSIn a recent study, patients with CS had an ischemic stroke recurrence rate of 9.1% (range, 6.2%-12.0%), 24.0% (range, 19.1%-28.9%), and 31.9% (range, 25.2%-38.6%) at 1, 5, and 10 years, respectively. 5 Recurrent stroke in these patients was classified again as cryptogenic in 63% of cases. 5 Stroke recurrence rate in ESUS was also reported to be high and similar to CS. 6 Possible causes of stroke recurrence, irrespective of the mechanism of the index stroke, are paroxysmal atrial fibrillation (AF), arterial sources of thromboembolism (TE), patent foramen ovale (PFO), cardiac structural abnormalities, and other less common etiologies. Detection of AF after a CS or ESUS does not imply causality but still offers an opportunity for reducing the risk of stroke recurrence by prescribing oral anticoagulation (OAC). However, AF is often asymptomatic, paroxysmal, and difficult to detect with conventional tools. Several monitoring strategies have been investigated to detect asymptomatic AF after an ischemic stroke, including electrocardiography (...

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“…Botto and colleagues, 8 using the groups: no subclinical AF (no AF or AF<6 min), AF of 6 min to 6 h, AF of 6-24 h and AF >24 h. 9 The stroke rates in the first three groups were not significantly different, with hazard ratios of 1, 0.93 and 1.39, respectively, whereas the AF >24 h group had a hazard ratio of 3.86 compared with the no subclinical AF group. Likewise, Boriani and Pettorelli reported that although a device-detected maximum daily burden of AF of at least 5-6 min was associated with an increase in the risk of stroke, the risk was particularly increased if the daily AFB was at least 1 h. 10 Consistent with the above, using 14-day continuous ambulatory recordings to document AF of at least 30 s, Go et al demonstrated that during follow up the rate of validated thromboembolic events off anticoagulants was 2.52/100 patient-years, with a higher crude rate with greater AF burden.…”

Section: Af Burdenmentioning

confidence: 99%

Optimum Risk Assessment for Stroke in Atrial Fibrillation: Should We Hold the Status Quo or Consider Magnitude Synergism and Left Atrial Appendage Anatomy?

Reiffel

2017

Arrhythmia &Amp; Electrophysiology Review

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Thromboembolic stroke and systemic embolism are generally agreed to be the major morbidity/mortality concerns for patients with AF.However, the risk of thromboembolism (TE) is not the same for all AF patients. While ECG rhythm strips of patients with AF are generally indistinguishable, it has long been known that AF in younger patients without co-morbid factors ("lone AF") carries an extremely low risk for TE, whereas AF in older patients in the presence of specific comorbidities carries a high TE risk.1,2 Thus, AF alone cannot sufficiently explain the risk. However, it has also been long known that older patients with conditions such as hypertension, diabetes and atherosclerotic disease also have an important risk for stroke, even in the absence of AF, 3,4 but that these same conditions in the presence of AF have been associated with a two to seven times greater risk of stroke than when AF is absent. 5 Thus, the comorbidities themselves also do not fully explain the total risk. Consequently, both AF and comorbidities must interact synergistically to magnify the risk for TE.But, is the synergism dichotomous -AF present or absent, comorbid disorder present or absent -or does synergism have magnitude, depending on the number and severity of the associated disorders and the amount of time one is in AF (AF burden, AFB)? I believe the latter is the case and that clinical trials addressing this point are warranted.Moreover, left atrial appendage (LAA) anatomy and the risk for stasis therein may also be a contributory factor to cardioembolic risk in AF.Thus, the line from AF to stroke is far from straight.To best understand the risk for TE in patients with AF, both synergism and the magnitude of the underlying components must be recognised.Historically, based on the presence of specific comorbidities, we have determined the risk for TE in AF patients as being either high enough to warrant prophylactic chronic oral anticoagulation (OAC) or too low to justify the risk of OAC-associated bleeding. A decade or so ago, such risk was assessed by determining the CHADS 2 score (Table 1), congestive heart failure, a history of hypertension, age 75 years or higher, diabetes (each 1 point), or prior thromboembolic event, e.g. ischemic stroke (2 points), and the paradigm was to determine from the score calculated which AF patients were at high enough risk to warrant OAC -generally agreed to be a score of 2 or more. 2 More recently, as we have recognised that stroke is much more likely to be fatal or debilitating than is bleeding, and as we have developed newer oral anticoagulants with preferable efficacy and safety profiles as compared to warfarin, the paradigm has shifted. We now ask which AF patients are at too low a score to warrant avoidance of OAC, with the rest having OAC indicated, and current guidelines 1,2 recommend the CHA 2 DS 2 -VASc score (Table 1), congestive heart failure, history of hypertension, age 65-74 years (each 1 point) or 75 years and above (2 points), vascular disease and female gender (each 1 point) to mak...

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Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT

Abstract: SCAF >24 h is associated with an increased risk of ischemic stroke or systemic embolism.

Cited by 498 publications

References 30 publications

Approach to device-detected subclinical atrial fibrillation

Approach to device-detected subclinical atrial fibrillation

Detection and management of atrial fibrillation after cryptogenic stroke or embolic stroke of undetermined source

Optimum Risk Assessment for Stroke in Atrial Fibrillation: Should We Hold the Status Quo or Consider Magnitude Synergism and Left Atrial Appendage Anatomy?

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