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Management of atrial high-rate episodes detected by cardiac implanted electronic devices

Key Points

  • Cardiac electronic implanted devices (CIEDs) readily detect atrial high-rate episodes (AHREs), which are fairly common and associated with an increased incidence of clinical atrial fibrillation, stroke, and systemic thromboembolism

  • Up to 20% of automatically detected AHREs reflect something other than an atrial arrhythmia, and inspection of the atrial electrogram is required for verification

  • The absolute risk of stroke associated with AHRE detection is lower than in patients with clinical atrial fibrillation who have similar clinical risk factors for stroke

  • The temporal relationship between AHREs and stroke is poor in most patients with a CIED who develop a stroke

  • In 15% of patients with stroke and a high AHRE burden, a close temporal relationship exists between the AHREs and stroke, which declines after 5 days

  • Two large clinical trials of anticoagulant drugs in CIED-detected AHREs are ongoing; their outcomes will inform future management

Abstract

Cardiac implanted electronic devices (CIEDs), including pacemakers and implantable defibrillators that perform atrial sensing typically using an atrial electrode, frequently detect subclinical atrial high-rate episodes (AHREs). When the intracardiac electrograms are carefully examined, the majority of AHREs are atrial fibrillation (AF) or other atrial tachyarrhythmias, which have been shown to be associated with both an increased risk of stroke, and subsequent development of clinical AF. However, the absolute risk of stroke among patients with AHREs is less than might be expected for clinically diagnosed paroxysmal AF. In addition, a close temporal relationship between AHREs and stroke is seen in only 15% of strokes in patients with a CIED: the majority have either no AHREs before the stroke, or AHREs very distant from incident stroke, suggesting that AHREs might be more of a risk marker than a risk factor for stroke. Management of AHREs should not be the same as for clinical AF, and a degree of uncertainty underpins the rationale for much-needed, ongoing, randomized trials of oral anticoagulation in patients with CIED-detected AHREs. We propose a management algorithm that takes into account both the stroke risk and the AHRE burden, but highlights the current uncertainty and evidence gaps for this condition.

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Figure 1: Cardiac implanted devices and leads.
Figure 2: Examples of appropriate and inappropriate detection of AHREs by CIEDs.
Figure 3: Temporal relationship between CIED-detected AHREs and stroke or systemic embolism.
Figure 4: Temporal relationship between CIED-detected AHREs and stroke or systemic embolism.
Figure 5: Proposed clinical management approach to CIED-detected AHREs.

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Acknowledgements

P.K. has received grants from several public funding bodies, including EU grant agreement No. 633196 (CATCH ME), British Heart Foundation (FS/13/43/30324), and Leducq Foundation.

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All the authors researched data for the article, discussed its content, wrote the manuscript, and reviewed and edited it before submission.

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Correspondence to Ben Freedman.

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B.F. declares that he has received speakers' fees and advisory board honoraria from Bayer Pharma AG, BMS/Pfizer, and Boehringer Ingelheim. G.B. declares that he has received honoraria (as speakers' fees) from Boston Scientific and Medtronic. T.V.G. declares that she has received a speaking honorarium from Medtronic. J.H. declares that he has received grants from Bayer, Boehringer Ingelheim, Bristol-Meyers-Squibb, and Medtronic. P.K. declares that he has received grants and personal fees from several industry companies involved in producing AF therapies (including Bayer Healthcare, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi-Sankyo, Medtronic, Pfizer, and Servier); grants and personal fees from AFNET, ESC, and other professional societies and academic organizations; and has patents on 'AF therapy' and 'Markers for AF' pending to the University of Birmingham, UK. T.S.P. declares no competing interests.

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Freedman, B., Boriani, G., Glotzer, T. et al. Management of atrial high-rate episodes detected by cardiac implanted electronic devices. Nat Rev Cardiol 14, 701–714 (2017). https://doi.org/10.1038/nrcardio.2017.94

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