Device-detected atrial high rate episodes and the risk of stroke/thrombo-embolism and atrial fibrillation incidence: a systematic review and meta-analysis
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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2023, European Journal of Internal MedicineCitation Excerpt :In this paper the authors also showed how patients found with SCAF have a significant higher risk profile, with higher prevalence of several comorbidities associated with a higher thromboembolic risk [14]. In another meta-analysis, Vitolo and colleagues demonstrated that patients with SCAF have a significant higher risk for thromboembolic events (approximately 2 fold, irrespective of AF previous history) and clinical AF (more than 3 fold) [15]. Really interesting, Ungar and colleagues also demonstrated that in a real-world cohort of patients diagnosed with cryptogenic stroke which received a CIED implant after the clinical event, up to 31.5% of patients were found with SCAF over a 24 months of follow-up [16].
Epidemiology of subclinical atrial fibrillation in patients with cardiac implantable electronic devices: A systematic review and meta-regression
2022, European Journal of Internal MedicineCitation Excerpt :The occurrence of AHRE, which is nowadays assimilated as the term of ‘subclinical atrial fibrillation (SCAF), is defined as asymptomatic atrial tachyarrhythmias detected only with long-term continuous cardiac monitoring and not through usual electrocardiographic means [8]. In this clinical context, AHRE/SCAF has been associated with an increased risk of developing clinical AF and an increased risk of stroke and systemic embolism [8,9]. Thus far, a highly variable incidence of AHRE/SCAF has been reported, basically depending on patients’ clinical characteristics [8].
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Joint first authors