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. 2020 Dec 22;22(Suppl O):O42-O52.
doi: 10.1093/eurheartj/suaa179. eCollection 2020 Dec.

What do we do about atrial high rate episodes?

Giuseppe Boriani  1 , Marco Vitolo  1   2 , Jacopo Francesco Imberti  1 , Tatjana S Potpara  3   4 , Gregory Y H Lip  2   5
Affiliations

What do we do about atrial high rate episodes?

Giuseppe Boriani et al. Eur Heart J Suppl. .

Abstract

Atrial high rate episodes (AHREs) are defined as asymptomatic atrial tachyarrhythmias detected by cardiac implantable electronic devices with atrial sensing, providing automated continuous monitoring and tracings storage, occurring in subjects with no previous clinical atrial fibrillation (AF) and with no AF detected at conventional electrocardiogram recordings. AHREs are associated with an increased thrombo-embolic risk, which is not negligible, although lower than that of clinical AF. The thrombo-embolic risk increases with increasing burden of AHREs, and moreover, AHREs burden shows a dynamic pattern, with tendency to progression along with time, with potential transition to clinical AF. The clinical management of AHREs, in particular with regard to prophylactic treatment with oral anticoagulants (OACs), remains uncertain and heterogeneous. At present, in patients with confirmed AHREs, as a result of device tracing analysis, an integrated, individual and clinically-guided assessment should be applied, taking into account the patients' risk of stroke (to be reassessed regularly) and the AHREs burden. The use of OACs, preferentially non-vitamin K antagonists OACs, may be justified in selected patients, such as those with longer AHREs durations (in the range of several hours or ≥24 h), with no doubts on AF diagnosis after device tracing analysis and with an estimated high/very high individual risk of stroke, accounting for the anticipated net clinical benefit, and informed patient's preferences. Two randomized clinical trials on this topic are currently ongoing and are likely to better define the role of anticoagulant therapy in patients with AHREs.

Keywords: Anticoagulation; Atrial fibrillation; Atrial high rate episodes; Continuous monitoring; Pacemaker; Stroke; Subclinical atrial fibrillation; Thrombo-embolic risk.

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Figures

Figure 1
Figure 1
Atrial high rate episode (AHRE) detected by a dual-chamber pacemaker and the corresponding intracavitary electrogram (EGM).
Figure 2
Figure 2
Incidence of CIED-detected AHREs on the basis of data from literature (refs30–40). AF, atrial fibrillation; AHRE, atrial high-rate episode; CIED, cardiac implanted electronic device; SVT, supraventricular tachycardia.
Figure 3
Figure 3
(A) Association between subclinical and clinical AF. (B) Association of subclinical atrial fibrillation and stroke risk. From Mahajan et al., with permission. AF, atrial fibrillation; AHRE, atrial high-rate episode.
Figure 4
Figure 4
Risk of stroke in patients with AHREs when compared with patients with no AHREs or AHREs below the threshold and the observed actual rate of stroke/systemic embolism in studies from the literature (refs.30,32,35–37,39,49). AHRE, atrial high rate episode.
Figure 5
Figure 5
Clinical management approach to CIED-detected AHREs according to the ESC Guidelines. From ref., with permission. AF, atrial fibrillation; AHRE, atrial high rate episode; OAC, oral anticoagulant; SCAF, subclinical atrial fibrillation.
See this image and copyright information in PMC

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