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. 2025 Jul 9:S1547-5271(25)02631-1.
doi: 10.1016/j.hrthm.2025.07.002. Online ahead of print.

Atrial fibrillation progression in patients with device-detected subclinical atrial fibrillation: Insights from the ARTESiA trial

Giuseppe Boriani  1 , William F McIntyre  2 , Chinthanie Ramasundarahettige  3 , Marco Proietti  4 , Taya V Glotzer  5 , Igor Diemberger  6 , Jens Cosedis Nielsen  7 , Vidal Essebag  8 , Christopher B Granger  9 , Roopinder K Sandhu  10 , Juan Benezet-Mazuecos  11 , Philippe Mabo  12 , Benoit Coutu  13 , Jorge A Wong  3 , Michael R Gold  14 , Renato D Lopes  9 , Jeffrey S Healey  2 ; ARTESiA Investigators
Affiliations

Atrial fibrillation progression in patients with device-detected subclinical atrial fibrillation: Insights from the ARTESiA trial

Giuseppe Boriani et al. Heart Rhythm. .

Abstract

Background: The Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Subclinical Atrial Fibrillation (ARTESiA) trial enrolled patients with subclinical atrial fibrillation (SCAF) lasting < 24 hours.

Objective and methods: We assessed the association of SCAF progression to clinical atrial fibrillation or SCAF > 24 hours with adverse outcomes and predictors of SCAF progression.

Results: During follow-up (4.1 ± 1.7 years), SCAF progressed in 1250 of 4012 patients (31.2%) at a rate of 9.3% per patient-year. SCAF progression was associated with adverse outcomes, with the following hazard ratios (HRs) and 95% confidence intervals (CIs): all-cause death, 2.12 (1.83-2.45); heart failure death, 4.81 (3.19-7.27); and arrhythmic death, 2.62 (1.58-4.35). The rate of stroke/systemic embolism in patients who remained on blinded aspirin therapy after SCAF progression was 1.42% per patient-year. If one limits the definition of progression to SCAF lasting > 24 hours, the rate was 1.75% per patient-year. Baseline variables modestly predicted SCAF progression (C statistic 0.59; 95% CI 0.57-0.61), including age (HR 1.02 per year; 95% CI 1.01-1.03 per year), male sex (HR 1.30; ; 95% CI 1.14-1.47), heart failure (HR 1.28; 95% CI 1.13-1.46), diabetes mellitus (HR 1.18; 95% CI 1.04-1.34), left atrial diameter > 4.1 cm (HR 1.28; 95% CI 1.08-1.52), and longest baseline SCAF episode duration > 1 hour (HR 1.59; 95% CI 1.42-1.79).

Conclusion: SCAF progression occurred in >9% of patients per year and was associated with a doubling of the risk of all-cause mortality, driven by increases in both heart failure-related and arrhythmic deaths. Patients who remained on aspirin after SCAF progression had an annual rate of stroke/systemic embolism of 1.42%, which is higher than the threshold currently proposed for oral anticoagulant prophylaxis.

Keywords: Anticoagulants; Aspirin; Atrial cardiomyopathy; Atrial fibrillation; Bleeding; Defibrillators; Pacemakers; Progression; Stroke; Thromboembolism.

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Conflict of interest statement

Disclosures Dr Boriani reports receiving speaker’s fees (a small amount) from Boston, Bayer, Bristol Myers Squibb, Daiichi Sankyo, Sanofi, and Janssen (all outside the submitted work). Dr Essebag reports receiving honoraria from Abbott, Adagio Therapeutics, Biosense Medical, Boston Scientific, and Medtronic. He is the recipient of a Clinical Research Scholar Award from the Fonds de recherche du Québec - Santé (FRQS). Dr Granger reports receiving consulting fees from AbbVie, Abiomed, Alnylam Pharmaceuticals, Amgen, Anthos Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Cardionomics, CeleCor Therapeutics, Janssen, Merck, Novo Nordisk, Novartis, Pfizer, Philips, and Roche. He also reports receiving salary support funded by Duke research grants sponsored by Alnylam Pharmaceuticals, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Janssen, National Heart, Lung, and Blood Institute, Novartis, Pfizer, and Philips and holds equity in Tenac.io. Dr Gold reports receiving consulting and speaker’s fees from and serving on steering committees for Boston Scientific, Abbott, and Medtronic. Dr Lopes reports receiving research grants from Amgen, Boehringer Ingelheim, Bristol Myers Squibb, GlaxoSmithKline, Medtronic, Novo Nordisk, Pfizer, and Sanofi US Services Inc. and serving as a consultant for Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi Sankyo, GlaxoSmithKline, Medtronic, Merck, Novo Nordisk, Pfizer, Portola Pharmaceuticals, and Sanofi US Services Inc. Dr Healey reports receiving research grants from Boston Scientific, Bristol Myers Squibb, Medtronic, and Pfizer and serving as a consultant for Bayer, Boston Scientific, Medtronic, Novartis, and Servier Affaires Médicales. No conflicts were reported by the other authors.

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