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. 2023 Jul 4;25(7):euad166.
doi: 10.1093/europace/euad166.

The influence of atrial high-rate episodes on stroke and cardiovascular death: an update

Tobias Toennis  1   2 , Emanuele Bertaglia  3 , Axel Brandes  4   5 , Wolfgang Dichtl  6 , Nina Fluschnik  1   2 , Joris R de Groot  7 , Eloi Marijon  8 , Lluis Mont  9 , Carina Blomström Lundqvist  10   11 , Nuno Cabanelas  12 , G Andrei Dan  13 , Andrzej Lubinski  14 , Béla Merkely  15 , Kim Rajappan  16 , Andrea Sarkozy  17 , Vasil Velchev  18 , Dan Wichterle  19 , Paulus Kirchhof  1   2   20   21
Affiliations

The influence of atrial high-rate episodes on stroke and cardiovascular death: an update

Tobias Toennis et al. Europace. .

Abstract

Atrial high-rate episodes (AHRE) are atrial tachyarrhythmias detected by continuous rhythm monitoring by pacemakers, defibrillators, or implantable cardiac monitors. Atrial high-rate episodes occur in 10-30% of elderly patients without atrial fibrillation. However, it remains unclear whether the presence of these arrhythmias has therapeutic consequences. The presence of AHRE increases the risk of stroke compared with patients without AHRE. Oral anticoagulation would have the potential to reduce the risk of stroke in patients with AHRE but is also associated with a rate of major bleeding of ∼2%/year. The stroke rate in patients with AHRE appears to be lower than the stroke rate in patients with atrial fibrillation. Wearables like smart-watches will increase the absolute number of patients in whom atrial arrhythmias are detected. It remains unclear whether anticoagulation is effective and, equally important, safe in patients with AHRE. Two randomized clinical trials, NOAH-AFNET6 and ARTESiA, are expected to report soon. They will provide much-needed information on the efficacy and safety of oral anticoagulation in patients with AHRE.

Keywords: Anticoagulation; Atrial fibrillation; Atrial high-rate episodes; Continuous monitoring; Implantable cardiac monitor; Pacemaker; Stroke; Sub-clinical atrial fibrillation; Thrombo-embolic risk.

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Conflict of interest statement

Conflict of interest: T.T. received speaker fees from Medtronic and honoraria from Boston Scientific. A.B. received honorarium from Boehringer-Ingelheim, Bristol-Myers Squibb and received research grants from Theravance, Zealand Region, Canadian Institutes of Health Research and the Danish Heart Foundation. N.F. received a grant from Biotronik, speaker fees from Abbott, Medtronic, all outside the submitted work. J.R.G. receives consultant or speaker fees from Atricure, Daiichi Sakyo, Bayer, and Novartis. He received research funding through institution from Abbott, Boston Scientific, Medtronic, Atricure, and Owner RhythmCare. E.M. receives consultant fees from Abbott, Bayer, Boston Scientific, Medtronic, and Zoll Carina Blomström Lundqvist received honorarium from Medtronic, Boston Scientific, Abbott, Bayer, Sanofi, Organon, Milestone, Philips, Cathprint outside this work. G.-A.D. receives speaker and consultation fees from Boehringer Ingelheim, Bayer, Novartis, Berlin Chemie, Amgen, Sanofi; nothing linked to the submitted work. B.M. received speaker fees from Abbott, Astra Zeneca, Biotronik, Boehringer Ingelheim, Novartis. Paulus Kirchhof receives research support for basic, translational, and clinical research projects from European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (UK), and German Centre for Cardiovascular Research, from several drug and device companies active in atrial fibrillation and has received honoraria from several such companies in the past, but not in the last 3 years (unrelated to the submitted work). P.K. is listed as inventor on two patents held by University of Birmingham (Atrial Fibrillation Therapy WO 2015140571, Markers for Atrial Fibrillation WO 2016012783). All remaining authors have declared no conflicts of interest.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Atrial high-rate episode detected by a dual-chamber pacemaker and the corresponding intracavitary electrogram. (A) Electrogram of a dual-chamber pacemaker (Abbott). AF, atrial fibrillation; AMS, atrial mode switch episode; AR, atrial signal in the refractory period; AS, atrial sensing; AT, atrial tachycardias; VS, ventricular sensing; VPP, ventricular backup pacing. (B) Electrogram and plot of a dual-chamber pacemaker (Medtronic).
Figure 2
Figure 2
Atrial arrhythmia detection rates in studies using PPG-based screening, ECG-based screening and continuous monitoring by a cardiac electronic implanted device (CIED). ECG, electrocardiogram; PPG, photoplethysmography
Figure 3
Figure 3
Hazard ratio for risk of thrombo-embolic event in patients with AHRE compared with patients without AHRE according to the longest duration of AHRE adapted from the observational studies by Witt et al. and van Gelder et al. (please see references). AHRE, atrial high-rate episode.
See this image and copyright information in PMC

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