Subclinical atrial fibrillation and the risk of stroke
Open accessAbstract
BACKGROUND: One quarter of strokes are of unknown cause, and subclinical atrial fibrillation may be a common etiologic factor. Pacemakers can detect subclinical episodes of rapid atrial rate, which correlate with electrocardiographically documented atrial fibrillation. We evaluated whether subclinical episodes of rapid atrial rate detected by implanted devices were associated with an increased risk of ischemic stroke in patients who did not have other evidence of atrial fibrillation. METHODS: We enrolled 2580 patients, 65 years of age or older, with hypertension and no history of atrial fibrillation, in whom a pacemaker or defibrillator had recently been implanted. We monitored the patients for 3 months to detect subclinical atrial tachyarrhythmias (episodes of atrial rate >190 beats per minute for more than 6 minutes) and followed them for a mean of 2.5 years for the primary outcome of ischemic stroke or systemic embolism. Patients with pacemakers were randomly assigned to receive or not to receive continuous atrial overdrive pacing. RESULTS: By 3 months, subclinical atrial tachyarrhythmias detected by implanted devices had occurred in 261 patients (10.1%). Subclinical atrial tachyarrhythmias were associated with an increased risk of clinical atrial fibrillation (hazard ratio, 5.56; 95% confidence interval [CI], 3.78 to 8.17; P<0.001) and of ischemic stroke or systemic embolism (hazard ratio, 2.49; 95% CI, 1.28 to 4.85; P=0.007). Of 51 patients who had a primary outcome event, 11 had had subclinical atrial tachyarrhythmias detected by 3 months, and none had had clinical atrial fibrillation by 3 months. The population attributable risk of stroke or systemic embolism associated with subclinical atrial tachyarrhythmias was 13%. Subclinical atrial tachyarrhythmias remained predictive of the primary outcome after adjustment for predictors of stroke (hazard ratio, 2.50; 95% CI, 1.28 to 4.89; P=0.008). Continuous atrial overdrive pacing did not prevent atrial fibrillation. CONCLUSIONS: Subclinical atrial tachyarrhythmias, without clinical atrial fibrillation, occurred frequently in patients with pacemakers and were associated with a significantly increased risk of ischemic stroke or systemic embolism. (Funded by St. Jude Medical; ASSERT ClinicalTrials.gov number, NCT00256152.).
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Retrieved CIED data provide insight into the natural history and associated sequelae of AF.
“Retrieved data provide an insight into the natural history and associated sequelae (Healey 2012, Kaplan 2019, Van Gelder 2017, Varma 2005).63,69,74,75”
From 2021 ISHNE/HRS/EHRA/APHRS Expert Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society (2021) · cites this paper as Healey 2012
Device-detected, subclinical, atrial, high-rate episodes lasting 6 minutes to 24 hours are associated with increased stroke risk, but the absolute risk is considerably lower than expected based on risk factors alone.
“Device-detected, subclinical, atrial, high-rate episodes lasting 6 minutes to 24 hours are associated with increased stroke risk, but the absolute risk is considerably lower than expected based on risk factors alone (Glotzer 2003, Healey 2012, van Gelder 2017).74,75,79”
From 2021 ISHNE/HRS/EHRA/APHRS Expert Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society (2021) · cites this paper as Healey 2012
AHRE are associated with an increased risk of ischaemic stroke or systemic embolism (HR 2.49; 95% CI 1.28-4.85; P=0.007).
“AHRE are associated with an increased risk of overt AF (hazard ratio [HR] 5.56; 95% confidence interval [CI] 3.78-8.17;P < 0.001) and ischaemic stroke or systemic embolism (HR 2.49; 95% CI 1.28-4.85;P = 0.007).”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [141]
Depending on the risk profile of the population studied, AHRE are detected in 10-15% of pacemaker patients.
“Depending on the risk profile of the population studied, such AHRE are detected in 10-15% of pacemaker patients.141”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [141]
AHRE are associated with an increased risk of overt AF (HR 5.56; 95% CI 3.78-8.17; P<0.001).
“AHRE are associated with an increased risk of overt AF (hazard ratio [HR] 5.56; 95% confidence interval [CI] 3.78-8.17;P < 0.001) and ischaemic stroke or systemic embolism (HR 2.49; 95% CI 1.28-4.85;P = 0.007).”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [141]
Traditional 24-h monitoring devices (Holter monitors) often do not detect symptomatic or clinically meaningful arrhythmias.
“Traditional 24-h monitoring devices (i.e., Holter monitors) often do not detect symptomatic or clinically meaningful arrhythmias [6, 7].”
From Incidence and timing of potentially high-risk arrhythmias detected through long term continuous ambulatory electrocardiographic monitoring (2016) · cites this paper as [6]
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Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation
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Stroke Risk as a Function of Atrial Fibrillation Duration and CHA 2 DS 2 -VASc Score
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Early management of atrial fibrillation to prevent cardiovascular complications
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Atrial fibrillation and cardiac fibrosis
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Hypertension and Atrial Fibrillation
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“An AF burden of at least 5 to 6 minutes is generally considered sufficient to start anticoagulation.(44,126) A European Consensus Document suggests commencing appropriate therapy (anticoagulation, ablation, etc) in hypertensive patients with arrhythmia confirmed either by (1) standard 12-lead ECG or (2) 24- to 48-hour…”
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Subclinical Atrial Fibrillation in Older Patients
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Searching for Atrial Fibrillation Poststroke
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- Authors
- Healey, J. S., Connolly, S. J., Gold, M. R., Israel, C. W., Van Gelder, I. C., Capucci, A., Lau, C. P., Fain, E., Yang, S., Bailleul, C., Morillo, C. A., Carlson, M., Themeles, E., Kaufman, E. S., & Hohnloser, S. H.
- Affiliations
- Population Health Research Institute (CA)
- Medical University of South Carolina (US)
- Goethe University Frankfurt (DE)
- Marche Polytechnic University (IT)
- Queen Mary Hospital (CN)
- MetroHealth (US)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2012-01-12
- Volume
- 366
- Issue
- 2
- Pages
- 120-129
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2154658516
- Cited by
- 2,100
- References
- 37
- Citations by year
- 2026: 87 · 2025: 104 · 2024: 137 · 2023: 116 · 2022: 134 · 2021: 153 · 2020: 148 · 2019: 162 · 2018: 154 · 2017: 154 · 2016: 162 · 2015: 146 · 2014: 181 · 2013: 133 · 2012: 124
- FWCI
- 120.21
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (publishedVersion)
- Università Politecnica delle Marche (Università Politecnica delle Marche) (submittedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Keywords
- subclinical atrial fibrillation, atrial tachyarrhythmia, ischemic stroke, systemic embolism, atrial overdrive pacing, atrial fibrillation risk, hypertension, elderly patients, population attributable risk, stroke prevention, cardiac implantable electronic devices, atrial fibrillation detection, atrial fibrillation prevention
- MeSH terms
- Aged, Aged, 80 and over, Atrial Fibrillation, Cardiac Pacing, Artificial, Embolism, Female, Humans, Hypertension, Male, Pacemaker, Artificial, Prospective Studies, Risk, Defibrillators, Implantable, Stroke
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