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March 2017

The Role of Cardiovascular Implantable Electronic Devices in the Detection and Treatment of Subclinical Atrial Fibrillation: A Review

Author Affiliations
  • 1Cardiology Section, Veterans Affairs Eastern Colorado Health System, Denver
  • 2Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
  • 3Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
  • 4Duke Clinical Research Institute, Durham, North Carolina
  • 5Medtronic Cardiac Rhythm Disease Management Research, Minneapolis, Minnesota
  • 6Lankenau Medical Research Institute, Philadelphia, Pennsylvania
  • 7Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
  • 8University of Missouri School of Medicine, Columbia
  • 9Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
JAMA Cardiol. 2017;2(3):324-331. doi:10.1001/jamacardio.2016.5167

Importance  Subclinical atrial fibrillation (AF) is associated with an increased risk for stroke.

Observations  Subclinical AF is asymptomatic, short in duration, and usually detected with long-term, continuous monitoring. Most prior studies have explored its consequences using cardiovascular implantable electronic devices (CIEDs). Although current prevalence estimates are derived from study populations with prior CIEDs, 3 trials will assess the time to a first AF diagnosis among patients receiving a CIED for purposes of AF detection. Stroke risk estimates are currently limited to patients with a prior CIED and vary widely, ranging from a hazard ratio of 0.87 (95% CI, 0.58-1.31) to 9.40 (95% CI, 1.80-47.00). Stroke risk pathogenesis may include factors that are proximately causal, upstream risk activators, and risk markers. The treatment of subclinical AF may be a useful stroke prevention strategy; however, no direct evidence of benefit from oral anticoagulation exists in this population. Two ongoing trials will assess the risk and benefit of non–vitamin K oral anticoagulants among patients at high risk for stroke with a previously placed implantable CIED, but without a prior diagnosis of clinical AF. If clinical benefit is proven, then the cost-effectiveness of screening for and the treatment of subclinical AF will require additional study.

Conclusions and Relevance  At present, no evidence suggests that implanting a CIED to detect AF or initiating oral anticoagulation therapy among those in whom AF is detected is beneficial. Ongoing and future studies will identify people at high risk for developing subclinical AF and will evaluate the efficacy, safety, and economic value of oral anticoagulation therapy in this population.

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