Win or tie? Rethinking anticoagulation in device-detected AF

This invited editorial refers to ‘Effects of anticoagulation in patients with device-detected atrial fibrillation and multiple stroke risk factors: a win ratio analysis of the NOAH-AFNET 6 trial’, by N. Becher et al., https://doi.org/10.1093/ehjqcco/qcaf087. Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and remains a leading cause of cardioembolic stroke, heart failure, and cardiovascular mortality.1 Its public health burden is substantial, with prevalence steadily increasing as populations age and diagnostic modalities advance. Against this backdrop, the management of patients with sub-clinical or device-detected AF has emerged as one of the most debated questions in contemporary electrophysiology. In contrast to electrocardiographically documented AF, where the association with thromboembolic risk is unequivocal and guidelines recommend anticoagulation for patients with CHA2DS2-VA scores ≥2, device-detected AF presents a therapeutic dilemma. These patients, often elderly and equipped with implantable devices, have a lower risk of stroke than those with overt AF, but not a negligible one. At the same time, initiation of oral anticoagulation exposes them to a marked increase in major bleeding. Recent randomized trials, most prominently NOAH-AFNET 62 and ARTESiA,3 have demonstrated that the annual risk of stroke in device-detected AF is ∼1%, well below the threshold at which anticoagulation with direct oral anticoagulants (DOACs) reliably yields net clinical benefit in AF.