What is the clinical evidence from this study?

Study design: Cohort. Population: Patients with cardiac implantable electronic devices (CIEDs) (n=856). Intervention: Atrial high rate episodes (AHREs) vs. No AHREs. Primary outcome: Thromboembolism (HR 3.40, 95% CI 1.38-8.37, p=0.01).

What does this research mean for the field?

Atrial high rate episodes detected by cardiac implantable electronic devices are independently associated with an increased risk of thromboembolism and death, and their addition to clinical risk scores improves risk discrimination. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

February 13, 2019Open Access

Atrial high rate episodes in patients with cardiac implantable electronic devices: implications for clinical outcomes

Resultado clave

Atrial high rate episodes detected by cardiac implantable electronic devices were independently associated with an increased risk of thromboembolism (HR 3.40) and death (HR 3.47).

Diseño del estudio

Tipo

Cohort (n=856)

Multicéntrico

PICO estructurado

Does the presence of atrial high rate episodes (AHREs) increase the risk of thromboembolism or all-cause death in patients with dual-chamber cardiac implantable electronic devices?

Población

856 consecutive patients who had dual-chamber cardiac implantable electronic devices (CIEDs: pacemaker, ICD, and CRT) implanted, median age 72.0 years, 39.3% female, from the United Kingdom. Excluded patients with single-chamber CIEDs and <6 months of follow-up.

Intervención

Presence of atrial high rate episodes (AHREs) lasting at least 5 min with atrial rate ≥175 beats per minute detected within the first 6 months after CIED implantation.

Comparador

Absence of atrial high rate episodes (AHREs) within the first 6 months after CIED implantation.

Resultado

Composite of thromboembolism (ischemic stroke, transient ischemic attack, or systemic embolism) or all-cause death 6 months after CIEDs' implantation.composite

Atrial high rate episodes detected by cardiac implantable electronic devices are independently associated with an increased risk of thromboembolism and all-cause death, and their addition to clinical risk scores improves risk discrimination.

Resultado numérico

Estimación del efecto: HR 3.40 (95% CI 1.38-8.37)

Tasa de eventos absoluta: 2.6% vs 0.9%

valor p: p=0.01

Limitaciones

Single-center, retrospective, and observational study in a hospital-based setting
Relatively small number of patients which may have reduced detection power
Clinical data collected only at the time of CIEDs' implantation, without follow-up data on initiation or discontinuation of oral anticoagulants
Lack of data on the quality of anticoagulation such as international normalized ratio or time in therapeutic range

Resumen

Atrial high rate episodes (AHREs) detected by cardiac implantable electronic devices (CIEDs) are associated with an increased risk of stroke. However, the impact of AHRE on improving stroke risk stratification scheme remains uncertain. The purpose of this study was to assess the impact of AHRE on prognosis in relation with cardiovascular events and risk stratification. A total of 856 consecutive patients who had dual-chamber CIEDs implanted were retrospectively analyzed. To detect AHREs, they were monitored for 6 months after CIEDs’ implantation and were followed for a mean of 4.0 years for clinical outcomes such as thromboembolism or death. Overall, 125 (14.6%) of patients developed AHREs within the first 6 months (median age 72.0 years, 39.3% female). Patients with AHREs had a high rate of thromboembolism (2.6%/year) and mortality (3.0%/year). On multivariate analysis, AHRE was significantly associated with increased risk of thromboembolism hazard ratio (HR) 3.40; 95% confidence interval (CI) 1.38–8.37, P = 0.01 and death (HR 3.47; 95% CI 1.51–7.95; P < 0.01). The predictive abilities of the CHADS2 and CHA2DS2-VASc scores were modest, with no significant improvements by adding AHRE to those scores. However, the integrated discrimination improvement and net reclassification improvement showed that the addition of AHRE to the CHADS2 and CHA2DS2-VASc scores statistically improved their predictive ability for the composite outcome. AHRE was an independent factor associated with increased risk of clinical outcomes. The addition of AHRE to the clinical risk scores significantly improved discrimination for thromboembolism or death.

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