Device-detected atrial high rate episodes and the risk of stroke/thrombo-embolism and atrial fibrillation incidence: a systematic review and meta-analysis

https://doi.org/10.1016/j.ejim.2021.05.038Get rights and content

Highlights

  • The actual risk of stroke/thrombo-embolism and progression to clinical Atrial Fibrillation (AF) in patients with device-detected Atrial High Rate Episodes (AHRE) markedly vary according to the different studies available in literature.

  • We performed a systematic review and meta-analysis of ten studies, for a total of 37 266 patients

  • In our meta-analysis, the detection of AHRE by implanted cardiac electronic devices is associated with a significantly increased risk of systemic thromboembolism and incident clinical AF during follow-up.

  • Further studies are needed to improve patients' risk stratification and management, in particular addressing the potential benefits of oral anticoagulant therapy in this setting.

Abstract

Background

Atrial High Rate Episodes (AHRE) are asymptomatic atrial tachy-arrhythmias detected through continuous monitoring with a cardiac implantable electronic device. The risks of stroke/Thromboembolic (TE) events and incident clinical Atrial Fibrillation (AF) associated with AHRE varies markedly.

Objectives

To assess the relationship between AHRE and TE events, and between AHRE and incident clinical AF.

Methods

This systematic review and meta-analysis was conducted following the PRISMA recommendations. PubMed, Scopus, and Google Scholar were searched from inception to 18/02/2021 for studies reporting TE events and incident clinical AF in patients with AHRE, as compared with patients without.

Results

Ten out of 8081 records fulfilled the inclusion criteria, for a total of 37 266 patients. Seven out of ten studies excluded patients with prior history of clinical AF (4961 patients), embracing the most recent definition of AHRE. The risk ratio (RR) for TE events in AHRE patients was 2.13 (95% CI: 1.53–2.95, I2: 0%). The incidence of clinical AF was reported in four studies excluding patients with a history of clinical AF (3574 patients). The RR for incident clinical AF was 3.34 (95%CI: 1.89–5.90, I2: 73%).

Conclusions

AHRE are significantly associated with systemic thromboembolism and incident clinical AF. Further studies are needed to improve patients' risk stratification and management.

Section snippets

1Introduction

Modern Cardiac Implantable Electronic Devices (CIEDs) allow continuous monitoring of cardiac electrical activity through one or more electrodes. Atrial High Rate Episodes (AHRE) are defined as device detected, asymptomatic, atrial tachy-arrhythmias, which are found in approximately 20–30% of CIED patients after 1 year of average follow-up.1,2 AHRE are associated with an increased risk of thromboembolic (TE) events and clinically overt Atrial Fibrillation (AF) (standard 12-lead ECG recording or

Methods

This systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) recommendations (http://www.prisma-statement.org).

Study selection

Electronic databases systematic search identified a total of 8081 records after duplicates removing. Of these, 8030 were excluded based on title and/or abstract. Fifty-one full-text articles were retrieved through the systematic literature search and 2 additional articles were identified based on authors’ knowledge. Relevant citations were assessed following the Patient/Population, Intervention, Comparison, Outcomes (PICO) process. Ten studies fulfilled the inclusion criteria and were included

Discussion

The main findings of our meta-analysis are: (i) patients with AHRE, even if appropriately selected on the basis of no previous history of AF, show a 2-fold higher risk of TE events, as compared with patients without AHRE, with no heterogeneity in the effect; and (ii) patients with AHRE have a three-fold higher risk of developing incident AF during follow-up, as compared to patients without AHRE.

AHRE are a relatively new clinical entity and there is no consensus on its most appropriate clinical

Limitations

Some limitations to our study should be acknowledged. Although we tried to include in the present meta-analysis only studies in which AHRE definition was as similar as possible to the one provided in the current ESC AF 2020 Guidelines 1, different cut-offs for AHRE duration and atrial rate were used across the various studies analyzed. The majority of the included studies were observational and about half were retrospective. Four out of ten studies included patients with prior clinical AF,

Conclusions

In a systematic analysis of the literature, adopting strict criteria for excluding patients with previous AF, detection of AHRE by cardiac implantable electronic devices is associated with a significantly increased risk of systemic thromboembolism and incident clinical AF during follow-up. Further studies are needed to improve patients' risk stratification and management, in particular addressing the potential benefits of OAC therapy in this setting.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaratio of Competing Interest

GB: small speaker fee from Medtronic, Boston, Boehringer Ingelheim and Bayer. JSH Research grants and speaking fees from Medtronic, Boston Scientific, Abbott, BMS-Pfizer, Servier and Bayer. GYHL: Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim and Daiichi-Sankyo. No fees are received personally. The other authors declare no conflicts of interest.

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