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Temporal Relationship Between Subclinical Atrial Fibrillation and Embolic Events
Open accessAbstract
BACKGROUND: Among patients with implantable pacemakers and defibrillators, subclinical atrial fibrillation (SCAF) is associated with an increased risk of stroke; however, there is limited understanding of their temporal relationship. METHODS AND RESULTS: The Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial (ASSERT) enrolled 2580 pacemaker and defibrillator patients aged ≥65 years with a history of hypertension but without a history of atrial fibrillation. Pacemakers and implantable cardioverter-defibrillators precisely logged the time and duration of all episodes of SCAF and recorded electrograms that were adjudicated by experts. We examined the temporal relationship between SCAF >6 minutes in duration and stroke or systemic embolism. Of 51 patients who experienced stroke or systemic embolism during follow-up, 26 (51%) had SCAF. In 18 patients (35%), SCAF was detected before stroke or systemic embolism. However, only 4 patients (8%) had SCAF detected within 30 days before stroke or systemic embolism, and only 1 of these 4 patients was experiencing SCAF at the time of the stroke. In the 14 patients with SCAF detected >30 days before stroke or systemic embolism, the most recent episode occurred at a median interval of 339 days (25th to 75th percentile, 211-619) earlier. Eight patients (16%) had SCAF detected only after their stroke, despite continuous monitoring for a median duration of 228 days (25th to 75th percentile, 202-719) before their event. CONCLUSIONS: Although SCAF is associated with an increased risk of stroke and embolism, very few patients had SCAF in the month before their event. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00256152.
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“The detection of supraventricular tachycardia (SVT) may be important as well as it is associated with the development of AF and an increased risk of stroke even in patients without AF (4–6).”
From Diagnostic Yield of Extended Cardiac Patch Monitoring in Patients with Stroke or TIA (2015) · cites this paper as [5]
Experimental — accuracy not yet measuredIn the citing paper
“Strokes often occur without AHRE detected within 30 days before the event.143-147”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [143]
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Smith, E. E., Yaghi, S. R., Sposato, L. A., Fisher, M., Broderick, J. P., Das, A. S., Elkind, M. S. V., Goldstein, L. B., Gurol, M. E., Kamel, H., et al. (2023) · Stroke · doi:10.1161/strokeaha.123.043665 · Cited by 17
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BackgroundAge-Dependence of Flow Homeostasis in the Left Ventricle
Benito, Y., Martínez‐Legazpi, P., Rossini, L., del Villar, C. P., Yotti, R., Peinador, Y. M., Pérez, D. R., Desco, M., Medrano, C., Antoranz, J. C., et al. (2019) · Frontiers in Physiology · doi:10.3389/fphys.2019.00485 · Cited by 17
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“Stroke may be the first symptom of atrial cardiomyopathy and is mediated by hyper-coagulability before the occurrence of blood stasis by AF (Brambatti et al., 2014; D’Alessandro et al., 2022).”
Clinical and echocardiographic characteristics of cardioembolic stroke
Ferkh, A., Brown, P., O’Keefe, E. J., Zada, M., Duggins, A., Thiagalingam, A., Altman, M., Boyd, A. C., Byth, K., Kizana, E., et al. (2019) · European Journal of Neurology · doi:10.1111/ene.13981 · Cited by 15
Infarto cerebral embólico de origen no determinado: más allá de la fibrilación auricular
Araúz, A., Arteaga, C., Zapata-Gómez, C., Ramos-Ventura, C., Méndez, B., Otiniano-Sifuentes, R. D., Haseeb, S., González-Oscoy, R., & Baranchuk, A. M. (2019) · Neurología · doi:10.1016/j.nrl.2019.03.008 · Cited by 15
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Kotadia, I., Sim, I., Mukherjee, R. K., O’Hare, D., Chiribiri, A., Birns, J., Bhalla, A., O'Neill, M. D., & Williams, S. E. (2021) · Journal of the American Heart Association · doi:10.1161/jaha.121.021045 · Cited by 15
Lower heart rates and beta-blockers are associated with new-onset atrial fibrillation
Habel, N., de Lavallaz, J. D. F., Infeld, M. M., Koehler, J. L., Ziegler, P., Lustgarten, D. L., & Meyer, M. (2023) · International Journal of Cardiology Cardiovascular Risk and Prevention · doi:10.1016/j.ijcrp.2023.200182 · Cited by 15
Hennings, E., Coslovsky, M., Paladini, R. E., Aeschbacher, S., Knecht, S., Schlageter, V., Krisai, P., Badertscher, P., Sticherling, C., Osswald, S., et al. (2023) · Cardiovascular Digital Health Journal · doi:10.1016/j.cvdhj.2023.01.003 · Cited by 15
Atrial Fibrillation and Objective Sleep Quality by Slow Wave Sleep
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Pisanò, E., Calvi, V. I., Viscusi, M., Rapacciuolo, A., Lazzari, L., Bontempi, L., Pelargonio, G., Arena, G., Caccavo, V., Wang, C.-C., et al. (2024) · EP Europace · doi:10.1093/europace/euae175 · Cited by 14
“30,34 The recent results of The Atrial Fibrillation Detected by Continuous Electrocardiogram Monitoring Using Implantable Loop Recorder to Prevent Stroke in High-Risk Individuals (LOOP) study 35 have even questioned the importance of long-term continuous AF screening with implantable loop recorders…”
BackgroundBhat, A., Khanna, S., Chen, H. H., Lee, L., Gan, G. C. H., Negishi, K., MacIntyre, C. R., Nunes, M. C. P., & Tan, T. C. (2019) · IJC Heart & Vasculature · doi:10.1016/j.ijcha.2019.100454 · Cited by 14
“However, interestingly there was a lack of a clear temporal relationship between arrhythmia and stroke development [5].”
BackgroundSaglietto, A., Ballatore, A., Xhakupi, H., Ferrari, G. M. D., & Anselmino, M. (2022) · Journal of Cardiovascular Development and Disease · doi:10.3390/jcdd9050140 · Cited by 14
“Several mechanisms may be involved: first, AF nduces electrical and structural a rial remodeling, which further sustain AF and wor en the u erlying a al disease, incre sing pe se th risk of stroke and va cular dementia [24].”
BackgroundKulesh, A. A., Евгеньевич, Д. В., & Shestakov, V. V. (2019) · Neurology neuropsychiatry Psychosomatics · doi:10.14412/2074-2711-2019-4-14-21 · Cited by 14
Clinical Impact of Oral Anticoagulation in Patients with Atrial High-rate Episodes
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Usefulness of P Wave Duration in Embolic Stroke of Undetermined Source
Jung, M., Kim, J. S., Song, J. H., Kim, J., Park, K., Lee, W. S., Kim, S., Lip, G. Y. H., & Shin, S. Y. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9041134 · Cited by 14
Wearable and implantable diagnostic monitors in early assessment of atrial tachyarrhythmia burden
Healey, J. S., & Wong, J. A. (2018) · EP Europace · doi:10.1093/europace/euy246 · Cited by 14
Self-citationNinni, S., Algalarrondo, V., Brette, F., Lemesle, G., & Fauconnier, J. (2024) · Archives of cardiovascular diseases · doi:10.1016/j.acvd.2024.02.001 · Cited by 13
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Impact of atrial fibrillation detected by extended monitoring—A population‐based cohort study
Busch, M., Groß, S., Alte, D., Kors, J. A., Völzke, H., Ittermann, T., Werner, A., Krüger, A., Busch, R., Dörr, M., et al. (2017) · Annals of Noninvasive Electrocardiology · doi:10.1111/anec.12453 · Cited by 13
“The MEANS program has been evaluated and validated extensively (de Bruyne et al., 1997).”
MethodLindow, T., & Lindqvist, P. (2021) · Journal of Clinical Medicine · doi:10.3390/jcm10132764 · Cited by 13
“Atrial fibrillation is common among patients with ATTR-CA [22], but although atrial fibrillation is a well-established risk factor for stroke, the reported lack of temporal relation suggests that it may not be the direct cause of embolism [30].”
BackgroundMonitoring for atrial fibrillation prior to patent foramen ovale closure after cryptogenic stroke
Diener, H., Wachter, R., Wong, A. A., Thijs, V., Schnabel, R. B., Ntaios, G., Kasner, S. E., Rothwell, P. M., PASSMAN, R. S., Saver, J. L., et al. (2022) · International Journal of Stroke · doi:10.1177/17474930221124412 · Cited by 13
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“Regarding the temporal dissociations between AHRE burden and the uncertainty of actual stroke risk in patients with AHRE [6], conjugation of the imaging approaches for the signs of atrial structural and functional changes with AHRE burden has been proposed to be useful for identifying the risk of…”
Diagnosis and Management of Cardioembolic Stroke
Yaghi, S. R. (2023) · CONTINUUM Lifelong Learning in Neurology · doi:10.1212/con.0000000000001217 · Cited by 13
Paroxysmal Atrial Fibrillation in Cryptogenic Stroke: an Overlooked Explanation?
Zhang, C., & Kasner, S. E. (2015) · Current Atherosclerosis Reports · doi:10.1007/s11883-015-0547-0 · Cited by 13
Yu, A., Malo, S., Wilton, S. B., Parkash, R., Svenson, L. W., & Hill, M. D. (2016) · CMAJ Open · doi:10.9778/cmajo.20150096 · Cited by 13
Understanding Atrial Cardiopathy: an Under-Recognized Contributor to Cardioembolic Stroke
Johansen, M. C., Vasconcellos, H. D. D., & Gottesman, R. F. (2019) · Current Treatment Options in Neurology · doi:10.1007/s11940-019-0571-4 · Cited by 13
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Long-term (>10-year) clinical follow-up after young embolic stroke/TIA of undetermined source
Nassif, M., Annink, M. E., Yang, H., Rettig, T. C. D., Roos, Y. B. W. E. M., van den Brink, R., Tijssen, J. G. P., Mulder, B. J. M., de Winter, R. J., & Bouma, B. J. (2019) · International Journal of Stroke · doi:10.1177/1747493019884520 · Cited by 13
“Although a cardio-embolic mechanism is speculated,(7) a temporal association between device-detected AF and embolic events has not been established yet.(9,10) Current studies on new-onset AF in the ESUS patient population primarily comprise older patients as well as subclinical device-detected AF, resulting in a signi…”
Diagnostic value of prehospital ECG in acute stroke patients
Bobinger, T., Kallmünzer, B., Kopp, M., Kurka, N., Arnold, M. B., Heider, S., Schwab, S., & Köhrmann, M. (2017) · Neurology · doi:10.1212/wnl.0000000000003940 · Cited by 13
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Metadata
- Authors
- Brambatti, M., Connolly, S. J., Gold, M. R., Morillo, C. A., Capucci, A., Muto, C., Lau, C. P., Van Gelder, I. C., Hohnloser, S. H., Carlson, M., Fain, E., Nakamya, J., Mairesse, G. H., Halytska, M., Deng, W. Q., Israel, C. W., & Healey, J. S.
- Affiliations
- Goethe University Frankfurt (DE)
- From the Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (M.B., S.J.C., C.A.M., J.N., M.H., W.Q.D., J.S.H.); Clinica di Cardiologia, Università Politecnica delle Marche, Ancona, Italy (M.B., A.C.); Medical University of South Carolina, Charleston (M.R.G.); Cardiology Department, Loreto Mare, Napoli, Italy (C.M.); Queen Mary Hospital, Department of Medicine, University of Hong Kong, Hong Kong, China (C.P.L.); University of Groningen, University Medical Center...
- ORCID
- Venue
- Circulation
- Published
- 2014-05-27
- Volume
- 129
- Issue
- 21
- Pages
- 2094-2099
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W2024497977
- Cited by
- 676
- References
- 31
- Citations by year
- 2026: 21 · 2025: 35 · 2024: 52 · 2023: 66 · 2022: 62 · 2021: 67 · 2020: 55 · 2019: 63 · 2018: 57 · 2017: 66 · 2016: 58 · 2015: 57 · 2014: 15
- FWCI
- 44.81
- Type
- journal article
- Language
- en
- Open access
- Licence
- other-oa
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Università Politecnica delle Marche (Università Politecnica delle Marche) (submittedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
- INFM-OAR (INFN Catania) (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Cardiovascular and Diving-Related Complications
- Keywords
- subclinical atrial fibrillation, stroke, systemic embolism, implantable cardioverter-defibrillator, cardiac pacemaker, temporal relations, asymptomatic atrial fibrillation, hypertension
- MeSH terms
- Aged, Aged, 80 and over, Atrial Fibrillation, Embolism, Female, Follow-Up Studies, Humans, Male, Pacemaker, Artificial, Prospective Studies, Risk Factors, Time Factors, Stroke
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