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Letter by Hess et al Regarding Article, “How to Manage Occult Atrial Fibrillation Detected on Long-Term Monitoring”

Originally published 2016;134:e28–e29

    To the Editor:

    In a Clinician Update, Dr Lip seems to recommend oral anticoagulation for all patients with device-detected atrial high-rate episodes (AHREs) and a CHA2DS2-VASc score of at least 1.1 Unfortunately, this recommendation is not evidence based. Although the TRENDS study (The Relationship Between Daily Atrial Tachyarrhythmia Burden From Implantable Device Diagnostics and Stroke Risk)2 and ASSERT (Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and Atrial Fibrillation Reduction Atrial Pacing Trial)3 have shown that device-detected AHREs are associated with an increased risk of stroke, both the relative and absolute risk of stroke are much lower than that observed among patients with traditional clinical atrial fibrillation. This has important implications for the risk-benefit ratio and for the cost-effectiveness of oral anticoagulation. Furthermore, TRENDS did not detect an increased risk of stroke for patients with a maximum daily burden of <5.5 hours,2 and ASSERT suggested that stroke risk was much greater among patients whose longest episode of device-detected AHREs lasted >24 hours.3 Because the majority of device-detected AHREs are of short duration, there is great uncertainty about the value of oral anticoagulation for these patients. The IMPACT trial (Combined Use of BIOTRONIK Home Monitoring and Predefined Anticoagulation to Reduce Stroke Risk) did not demonstrate any benefit of a remote-monitoring strategy for the identification and treatment of AHREs among patients with pacemakers.4 ARTESiA (A Comparison of Apixaban Versus Aspirin for Preventing Stroke in Patients with Pacemakers; URL: Unique identifier: NCT01938248) and NOAH (Non-vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes; URL: Unique identifier: NCT02618577) are large, randomized trials that are now underway and will determine whether non-vitamin K oral anticoagulants can reduce the risk of stroke and embolism in patients with device-detected AHREs of at least 6 minutes in duration. Until such data are available, it is difficult to give strong recommendations regarding these patients.

    Paul L. Hess, MD, MHSRenato D. Lopes, MD, MHS, PhDJeff S. Healey, MD, MSc


    Circulation is available at


    • 1. Lip GY. How to manage occult atrial fibrillation detected on long-term monitoring.Circulation. 2016; 133:1290–1295. doi: 10.1161/CIRCULATIONAHA.115.016797.LinkGoogle Scholar
    • 2. Glotzer TV, Daoud EG, Wyse DG, Singer DE, Ezekowitz MD, Hilker C, Miller C, Qi D, Ziegler PD. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study.Circ Arrhythm Electrophysiol. 2009; 2:474–480. doi: 10.1161/CIRCEP.109.849638.LinkGoogle Scholar
    • 3. Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, Lau CP, Fain E, Yang S, Bailleul C, Morillo CA, Carlson M, Themeles E, Kaufman ES, Hohnloser SH; ASSERT Investigators. Subclinical atrial fibrillation and the risk of stroke.N Engl J Med. 2012; 366:120–129. doi: 10.1056/NEJMoa1105575.CrossrefMedlineGoogle Scholar
    • 4. Martin DT, Bersohn MM, Waldo AL, Wathen MS, Choucair WK, Lip GY, Ip J, Holcomb R, Akar JG, Halperin JL; IMPACT Investigators. Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices.Eur Heart J. 2015; 36:1660–1668. doi: 10.1093/eurheartj/ehv115.CrossrefMedlineGoogle Scholar


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