Atrial high-rate episodes and risk of major adverse cardiovascular events in patients with cardiac implantable electronic devices

Abstract

Background: Patients with atrial high-rate episodes (AHREs) are at higher risk of thromboembolic events and mortality. The risk of major adverse cardiovascular events (MACE) in these patients is unknown.

Objective: To investigate the risk of MACE in patients implanted with cardiac implantable electronic devices (CIEDs) developing AHREs METHODS AND RESULTS: We included 852 consecutive patients undergoing CIEDs implantation. Primary outcome was a composite endpoint of MACEs occurring after AHREs ≥ 5 min. AHRE was defined as > 175 bpm and lasting ≥ 5 min. We also performed a subgroup analysis in patients with the longest AHRE lasting ≥ 24 h. Cox regression analysis with time-dependent covariates was used to investigate the relationship between AHREs and MACEs. Mean age was 70.0 ± 13.6 years, and 39.3% were women: 325 patients developed AHREs ≥ 5 min [incidence rate (IR) 13.1% year 95% confidence interval (CI) 11.7-14.6] and 124 patients developed AHREs ≥ 24 h (IR 3.7%/year 95% CI 3.1-4.5). During a median follow-up of 37.0 months (IQR 19.0-64.3, 316,132 patient-years), 152 MACEs occurred (IR 4.85%/year, 95% CI 4.11-5.68). The IR of MACE occurring after AHREs onset was higher in patients developing AHREs ≥ 24 h (IR 1.13%/year) than AHREs ≥ 5 min (IR 0.63%/year, p = 0.030). Multivariable Cox regression analysis showed that AHREs ≥ 5 min (HR 1.788, 95% CI 1.247-2.562, p = 0.002), diabetes (HR 1.909, 95% CI 1.358-2.683, p < 0.001), heart failure (HR 2.203, 95% CI 1.527-3.178, p < 0.001), and coronary artery disease (HR 1.862, 95% CI 1.293-2.681, p = 0.001) were associated to MACE. This association was even stronger for AHREs ≥ 24 h (HR 2.390, 95% CI 1.481-3.857, p < 0.001).

Conclusions: Patients implanted with CIEDs developing AHREs show a significant risk for MACE, which is dependent on AHREs burden. Cardiovascular prevention strategies in this patient population are warranted.

Keywords: AHREs; Atrial fibrillation; CIED; Cardiovascular risk; Implantable device; MACE; Myocardial infarction; Pacemaker.