Cited by 2,100Atrial Fibrillation Management and OutcomesAcute Ischemic Stroke ManagementCardiac pacing and defibrillation studies

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Subclinical Atrial Fibrillation and the Risk of Stroke

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Healey, Jeff S., Connolly, Stuart J., Gold, Michael R., Israel, Carsten W., Van Gelder, Isabelle C., Capucci, Alessandro, Lau, C.P., Fain, Eric, Yang, Sean, Bailleul, Christophe, Morillo, Carlos A., Carlson, Mark, Themeles, Ellison, Kaufman, Elizabeth S., Hohnloser, Stefan H.·2012·New England Journal of Medicine

DOI 10.1056/nejmoa1105575

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Abstract

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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Chhabra, L., & Gowdar, S. D. (2016) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2016.05.029 · Cited by 11
Measuring Success in Ablation of Atrial Fibrillation
Terricabras, M., Verma, A., & Morillo, C. A. (2018) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.118.006582 · Cited by 11
Does asymptomatic atrial fibrillation exist?
Carneiro, H. A., & Knight, B. P. (2023) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.16108 · Cited by 11
Atrial fibrillation progression in patients with device-detected subclinical atrial fibrillation: Insights from the ARTESiA trial
Boriani, G., McIntyre, W. F., Ramasundarahettige, C. F., Proietti, M., Glotzer, T. V., Diemberger, I., Nielsen, J. C., Essebag, V., Granger, C. B., Sandhu, R. K., et al. (2025) · Heart Rhythm · doi:10.1016/j.hrthm.2025.07.002 · Cited by 10
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A Critical Perspective on the Role of Catheter Ablation in Management of Atrial Fibrillation
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Atrial fibrillation post central retinal artery occlusion: Role of implantable loop recorders
Watson, R. A., Wellings, J., Hingorani, R., Zhan, T., Frisch, D. R., Ho, R. T., Pavri, B. B., Sergott, R. C., & Greenspon, A. J. (2020) · Pacing and Clinical Electrophysiology · doi:10.1111/pace.13990 · Cited by 10
Use of the HAVOC Score to Identify Patients at Highest Risk of Developing Atrial Fibrillation
Elkind, M. S. V., Wachter, R., Verma, A., Kowey, P. R., Halperin, J. L., Gersh, B. J., Ziegler, P., Pouliot, E., Franco, N. C., & Reiffel, J. A. (2021) · Cardiology · doi:10.1159/000517827 · Cited by 10
Meta-Analysis of Oral Anticoagulants and Adverse Outcomes in Atrial Fibrillation Patients After Intracranial Hemorrhage
Liu, X., Guo, S., & Xu, Z. (2022) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2022.961000 · Cited by 10
“The main findings of our meta-analysis on the effectiveness and safety outcomes of OAC versus no OAC in patients with AF after ICH are summarized as follows: (1) OAC was correlated with a lower risk of stroke or systemic embolism, ischemic stroke, and all-cause death but a similar risk of major bleeding and major recu…”
BackgroundResultInfluential
Silent Atrial Fibrillation after Ischemic Stroke or Transient Ischemic Attack: Interest of Continuous ECG Monitoring
Fernandez, V., Béjot, Y., Zeller, M., Hamblin, J., Daubail, B., Jacquin, A., Maza, M., Touzery, C., Cottin, Y., & Giroud, M. (2014) · European Neurology · doi:10.1159/000357561 · Cited by 10
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Antiplatelet agents in uncertain clinical scenarios—a bleeding nightmare
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“A recent systematic review, of over half a million participants post-PCI, found that major bleeding increased Table 2 Clinical risk factors associated with increased ischemic and bleeding risk (38-44)”
Background
Wytyczne ESC dotyczące stymulacji serca i terapii resynchronizującej w 2013 roku
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Parental Atrial Fibrillation and Stroke or Atrial Fibrillation in Young Adults
McAlister, F. A., Yan, L., Roos, L. L., & Lix, L. M. (2019) · Stroke · doi:10.1161/strokeaha.119.025124 · Cited by 11
“These AF codes in hospital discharge records have a specificity of >99% for identification of AF.9–11 We did not use ambulatory billing records in the algorithm to define parental AF because this would have increased the number of false positive diagnoses substantially: whereas hospital discharge records include digit…”
BackgroundInfluential
Predictors of atrial fibrillation detection and features of recurrent strokes in patients after cryptogenic stroke
Xu, J., Sethi, P. P., Biby, S., Allred, J. D., Seiler, A. K., & Sabir, R. (2020) · Journal of Stroke and Cerebrovascular Diseases · doi:10.1016/j.jstrokecerebrovasdis.2020.104934 · Cited by 10
Evaluation of the Feasibility and Efficacy of a Novel Device for Screening Silent Atrial Fibrillation (MYBEAT Trial)
Okubo, Y., Tokuyama, T., Okamura, S., Ikeuchi, Y., Miyauchi, S., Nakano, Y., & for the MYBEAT Trial Investigators (2021) · Circulation Journal · doi:10.1253/circj.cj-20-1061 · Cited by 10
Cor triatriatum sinister and cryptogenic stroke
Ridjab, D. A., Wittchen, F., Tschishow, W. N., Buddecke, J., Lamp, B., Manegold, J. C., Schäbitz, W., & Israel, C. W. (2013) · Herz · doi:10.1007/s00059-013-3934-8 · Cited by 10
Left Atrial Appendage Morphology and Physiology: “The Missing Piece in the Puzzle”
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Management of Device-detected Atrial High-rate Episodes
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Embolic Stroke of Undetermined Source in Latin America
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Conti, S., Reiffel, J. A., Gersh, B. J., Kowey, P. R., Wachter, R., Halperin, J. L., Kaplon, R. E., Pouliot, E., & Verma, A. (2017) · Journal of Atrial Fibrillation · doi:10.4022/jafib.1551 · Cited by 10
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Incremental Value of an Insertable Cardiac Monitor in Patients with Hypertrophic Cardiomyopathy with Low or Intermediate Risk for Sudden Cardiac Death
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Atrial Fibrillation in Cryptogenic Stroke
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Seek and Ye Shall Find Fibrillations
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Not All Types of Atrial Fibrillation Carry the Same Stroke Risk, but Most Benefit From Oral Anticoagulation
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Atrial fibrillation detection with long-term continuous Holter ECG recording in patients with high cardiovascular risk and clinical palpitations: the prospective after study
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Diagnostic Value of a Wearable Continuous Electrocardiogram Monitoring Device (AT-Patch) for New-Onset Atrial Fibrillation in High-Risk Patients: Prospective Cohort Study
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“Despite early detection and accurate diagnosis of arrhythmias being crucial for preventing adverse outcomes [5], atrial fibrillation is often both asymptomatic and intermittent, making it difficult to capture these episodic events [6,7].”
Association of Device-Detected Atrial High-Rate Episodes With Long-term Cardiovascular and All-Cause Mortality: A Cohort Study
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“…Reduction atrial pacing Trial) study demonstrated higher rates of clinical overt AF as well as strokes in patients with subclinical AF, defined as atrial high rate episodes ( AHRE) only detected by implanted devices ( mostly pacemakers and implantable cardioverter defibrillators) [11 ].”
Background
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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: Healey, Jeff S.
Connolly, Stuart J.
Gold, Michael R.
Israel, Carsten W.
Capucci, Alessandro
Fain, Eric
Bailleul, Christophe
Morillo, Carlos A.
Kaufman, Elizabeth S.
Hohnloser, Stefan H.
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
DOI: 10.1056/nejmoa1105575
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 › Clinical Neurology › 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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Subclinical Atrial Fibrillation and the Risk of Stroke

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