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In this episode of She Runs the World, Professor Kate McNamara joins Kaei Li and Emily Jaster to discuss recent developments in domestic and international politics. Dr. McNamara served as Director of the Mortara Center for International Studies from 2010 to 2016 and is currently a Professor of Government at Georgetown.
Long-term and continuous ECG monitoring using cardiac implantable electronic devices and insertable cardiac monitors has improved the capability of detecting subclinical atrial fibrillation (AF) and atrial high-rate episodes. Previous studies demonstrated a high prevalence (more than 20%) in patients with cardiac implantable electronic devices or insertable cardiac monitors. Subclinical AF and atrial high-rate episodes are often suspected as the cause of prior or potential future ischemic stroke. However, the clinical significance is still uncertain, and the evidence is limited. This review aims to present and discuss the current evidence on the clinical impact of subclinical AF and atrial high-rate episodes. It focuses particularly on the association between the duration of the episodes and major clinical outcomes like thromboembolic events. As subclinical AF and atrial high-rate episodes are presumed to be associated with ischemic strokes, detection will be particularly important in patients with cryptogenic stroke and in high-risk patients for thromboembolism. In this context, it is also interesting whether there is a temporal relationship between the detection of subclinical AF and atrial high-rate episodes and the occurrence of thromboembolic events. In addition, the review will examine the question whether there is a need for a therapy with oral anticoagulation.
Optimal threshold values for the duration of subclinical atrial fibrillation and atrial high-rate episodes for an increased thromboembolic risk in selected studies (with indication of the hazard ratio (HR)/odds ratio (OR))
An individualized decision-making using a management algorithm is required in all patients with atrial high-rate episodes to evaluate their risk of stroke [21,22,23]. The CHA2DS2-VASc score (congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age, and sex category) has been used for many years to assess the risk of stroke in patients with clinical AF [1]. However, the significance of the CHA2DS2-VASc score in patients with a low burden of subclinical AF or atrial high-rate episodes is ambiguous. In awareness of a possible progression to a higher burden or clinical AF, the ESC guidelines suggest risk stratification based on the duration of arrhythmia and the CHA2DS2-VASc score (Fig. 3) [1]. The current ESC guidelines recommend in patients with subclinical AF/atrial high-rate episodes a complete cardiovascular evaluation with ECG recording, clinical risk factors/comorbidity evaluation, and thromboembolic risk assessment using the CHA2DS2-VASc score. Moreover, continued patient follow-up and monitoring are recommended to detect a progression to clinical AF, monitor the subclinical AF/atrial high-rate episodes burden and detect changes in underlying clinical conditions [1].
This review aims to outline the current evidence with a focus on the impact of duration of subclinical AF/atrial high-rate episodes. In addition, the temporal relationship between subclinical AF/atrial high-rate episodes and thromboembolic events and the meaning in cryptogenic stroke and high-risk patients will be evaluated. Furthermore, the risk of progression to clinical AF will be elaborated. Within the scope of this, the value of oral anticoagulant therapy will also be discussed.
On the contrary, Li et al. [33] demonstrated in a study including 594 patients with cardiac implantable electronic devices that atrial high-rate episodes were not independently associated with thromboembolic events. The authors pointed out that comorbidity burden had a greater impact on the occurrence of thromboembolic events than atrial high-rate episodes by themselves.
However, in consideration that some studies have demonstrated an association between subclinical AF/atrial high-rate episodes and stroke, initiation of oral anticoagulant therapy in patients with subclinical AF/atrial high-rate episodes is discussed controversially. The evidence on the significance of subclinical AF/atrial high-rate episodes and on possible benefits of a therapy with oral anticoagulants in these patients is still doubtful.
An important question is whether longer episodes of subclinical AF/atrial high-rate episodes are associated with a higher incidence of thrombotic events. Very brief episodes of subclinical AF/atrial high-rate episodes ( 2ff7e9595c
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