Atrial High-Rate Episodes and Subclinical Atrial Fibrillation: State of the Art and Clinical Questions with Complex Solutions

Figures

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  Fig. 1.. A visual comparison between RCTs: ARTESIA and NOAH AFNET 6. Details of the two RCTs assessing the potential benefit of OAC (apixaban and edoxaban, respectively) versus aspirin or placebo on stroke prevention in patients with at least one episode of AHRE lasting more than 6 minutes. AHRE, atrial high-rate episodes; ASA, aspirin; CV, cardiovascular; HF, heart failure; HTN, hypertension; ICD, implantable cardioverter defibrillator; ICM, insertable cardiac monitor; OACs, oral anticoagulants; PM, pacemaker; SE, systemic embolism; T2DM, type 2 diabetes mellitus; TIA, transient ischemic attack; AF, atrial fibrillation; RCTs, randomized clinical trials.

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  Fig. 2.. Relationship between AHRE and thromboembolic risk. Even though a cut off duration for AHRE to predict thromboembolic events has not been identified, studies have shown that patients with either longer single-episode duration (especially when >24 hours) or higher cumulative burden are at increased risk of stroke. Latest guidelines suggest to weight in both these aspects and consider the start of anticoagulation therapy in patients with episodes >24 hours and a high monthly burden, after balancing between embolic and hemorrhagic risk. When single episodes are short and the daily burden is low, close follow-up is necessary to detect progression to a higher burden or clinical AF, possibly with the use of remote monitoring. Latest guidelines were released before the results of the two RCTs assessing the potential benefit of OACs in patients with episodes >6 minutes (and shorter than 24 hours in the ARTESIA trial). As discussed in the review, results from trials show a significant benefit of OACs in terms of reduction of stroke risk, particularly fatal or disabling stroke. This reduction is counterbalanced by an increase in major bleeding events, which could be managed conservatively…