Detection of new atrial fibrillation in patients with cardiac implanted electronic devices and factors associated with transition to higher device-detected atrial fibrillation burden

Published:November 06, 2017DOI:


      In patients with cardiac implanted electronic devices, detection of new atrial fibrillation (AF) is associated with an increased risk of stroke.


      To characterize daily AF burden at first detection and the rate of temporal transition to higher device-detected AF burden.


      A pooled analysis of data from 3 prospective projects was analyzed, and 6580 patients (mean age 68 ± 12 years, 72% male) with no history of AF and no use of anticoagulants at baseline were identified. Various thresholds of daily AF burden (5 minutes and 1, 6, 12, and 23 hours) were analyzed.


      Among the study population of 6580 patients, a new AF, with an AF burden of ≥5 minutes, was detected in 2244 patients (34%) during a follow-up period of 2.4 ± 1.7 years. Among these patients, 1091 (49.8%) transitioned to a higher AF-burden threshold during follow-up. A higher duration of daily AF burden manifest at first detection and CHADS2 score ≥2 were associated with faster transition to a subsequent higher burden. Approximately 24% of patients transitioned from a lower threshold to a daily AF burden of ≥23 hours during follow-up.


      More than one-third of patients with no history of AF developed device-detected AF, with attainment of different thresholds of daily AF burden over time. Continuous long-term monitoring, especially when the initial detection corresponds to a higher daily AF burden and the CHADS2 score is ≥2, could support timely clinical decisions on anticoagulation by capturing transitions to higher AF-burden thresholds.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Healey J.S.
        • Connolly S.J.
        • Gold M.R.
        • et al.
        • ASSERT Investigators
        Subclinical atrial fibrillation and the risk of stroke.
        N Engl J Med. 2012; 366: 120-129
        • Gorenek B.
        • Pelliccia A.
        • Benjamin E.J.
        • et al.
        European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS).
        Europace. 2017; 19: 190-225
        • Freedman B.
        • Boriani G.
        • Glotzer T.V.
        • Healey J.S.
        • Kirchhof P.
        • Potpara T.S.
        Management of atrial high-rate episodes detected by cardiac implanted electronic devices.
        Nat Rev Cardiol. 2017; 14: 701-714
        • Charitos E.I.
        • Pürerfellner H.
        • Glotzer T.V.
        • Ziegler P.D.
        Clinical classifications of atrial fibrillation poorly reflect its temporal persistence: Insights from 1,195 patients continuously monitored with implantable devices.
        J Am Coll Cardiol. 2014; 63: 2840-2848
        • Boriani G.
        • Pettorelli D.
        Atrial fibrillation burden and atrial fibrillation type: clinical significance and impact on the risk of stroke and decision making for long-term anticoagulation.
        Vascul Pharmacol. 2016; 83: 26-35
        • Boriani G.
        • Valzania C.
        • Biffi M.
        • Diemberger I.
        • Ziacchi M.
        • Martignani C.
        Asymptomatic lone atrial fibrillation-how can we detect the arrhythmia?.
        Curr Pharm Des. 2015; 21: 659-666
        • Glotzer T.V.
        • Daoud E.G.
        • Wyse D.G.
        • Singer D.E.
        • Ezekowitz M.D.
        • Hilker C.
        • Miller C.
        • Qi D.
        • Ziegler P.D.
        The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study.
        Circ Arrhythmia Electrophysiol. 2009; 2: 474-480
        • Boriani G.
        • Glotzer T.V.
        • Santini M.
        • West T.M.
        • De Melis M.
        • Sepsi M.
        • Gasparini M.
        • Lewalter T.
        • Camm J.A.
        • Singer D.E.
        Device-detected atrial fibrillation and risk for stroke: an analysis of >10 000 patients from the SOS AF project (Stroke prevention strategies based on atrial fibrillation information from implanted devices).
        Eur Heart J. 2014; 35: 508-516
        • Hess P.L.
        • Healey J.S.
        • Granger C.B.
        • Connolly S.J.
        • Ziegler P.D.
        • Alexander J.H.
        • Kowey P.R.
        • Ruff C.T.
        • Flaker G.
        • Halperin J.L.
        • Hart R.G.
        • Lopes R.D.
        The role of cardiovascular implantable electronic devices in the detection and treatment of subclinical atrial fibrillation.
        JAMA Cardiol. 2017; 2: 324-331
        • Kirchhof P.
        • Benussi S.
        • Kotecha D.
        • et al.
        2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
        Europace. 2016; 18: 1609-1678
        • Botto G.L.
        • Padeletti L.
        • Santini M.
        • et al.
        Presence and duration of atrial fibrillation detected by continuous monitoring: crucial implications for the risk of thromboembolic events.
        J Cardiovasc Electrophysiol. 2009; 20: 241-248
        • Boriani G.
        • Botto G.L.
        • Padeletti L.
        • Santini M.
        • Capucci A.
        • Gulizia M.
        • Ricci R.
        • Biffi M.
        • De Santo T.
        • Corbucci G.
        • Lip G.Y.
        • Italian AT-500 Registry Investigators
        Improving stroke risk stratification using the CHADS2 and CHA2DS2-VASc risk scores in patients with paroxysmal atrial fibrillation by continuous arrhythmia burden monitoring.
        Stroke. 2011; 42: 1768-1770
        • Van Gelder I.C.
        • Healey J.S.
        • Crijns H.J.G.M.
        • Wang J.
        • Hohnloser S.H.
        • Gold M.R.
        • Capucci A.
        • Lau C.P.
        • Morillo C.A.
        • Hobbelt A.H.
        • Rienstra M.
        • Connolly S.J.
        Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT.
        Eur Heart J. 2017; 38: 1339-1344
        • Lamas G.
        How much atrial fibrillation is too much atrial fibrillation?.
        N Engl J Med. 2012; 366: 178-180
        • Glotzer T.V.
        • Hellkamp A.S.
        • Zimmerman J.
        • Sweeney M.O.
        • Yee R.
        • Marinchak R.
        • Cook J.
        • Paraschos A.
        • Love J.
        • Radoslovich G.
        • Lee K.L.
        • Lamas G.A.
        • MOST Investigators
        Atrial high rate episodes detected by pacemaker diagnostics predict death and stroke: report of the atrial diagnostics ancillary study of the Mode Selection Trial (MOST).
        Circulation. 2003; 107: 1614-1619
        • Capucci A.
        • Santini M.
        • Padeletti L.
        • et al.
        • Italian AT500 Registry Investigators
        Monitored atrial fibrillation duration predicts arterial embolic events in patients suffering from bradycardia and atrial fibrillation implanted with antitachycardia pacemakers.
        J Am Coll Cardiol. 2005; 46: 1913-1920
        • Boriani G.
        • Padeletti L.
        Management of atrial fibrillation in bradyarrhythmias.
        Nat Rev Cardiol. 2015; 12: 337-349
        • Freedman B.
        • Camm J.
        • Calkins H.
        • et al.
        • AF-Screen Collaborators
        Screening for atrial fibrillation.
        Circulation. 2017; 135: 1851-1867
        • Healey J.S.
        Apixaban for the reduction of thrombo-embolism in patients with device-detected sub-clinical atrial fibrillation. Web site.
        (Updated May 30, 2017. Accessed on July 10, 2017)
        • Kirchhof P.
        Non-vitamin K antagonist oral anticoagulants in patients with atrial high rate episodes (NOAH). Web site.
        (Updated October 20, 2017. Accessed on July 10, 2017)
        • Kirchhof P.
        • Blank B.F.
        • Calvert M.
        • Camm A.J.
        • Chlouverakis G.
        • Diener H.C.
        • Goette A.
        • Huening A.
        • Lip G.Y.H.
        • Simantirakis E.
        • Vardas P.
        Probing oral anticoagulation in patients with atrial high rate episodes. Rationale and design of the non vitamin K antagonist oral anticoagulants in patients with atrial high rate episodes (NOAH-AFNET 6) trial.
        Am Heart J. 2017; 190: 12-18
        • Pollak W.M.
        • Simmons J.D.
        • Interian Jr., A.
        • Atapattu S.A.
        • Castellanos A.
        • Myerburg R.J.
        • Mitrani R.D.
        Clinical utility of intraatrial pacemaker stored electrograms to diagnose atrial fibrillation and flutter.
        Pacing Clin Electrophysiol. 2001; 24: 424-429
        • Purerfellner H.
        • Gillis A.M.
        • Holbrook R.
        • Hettrick D.A.
        Accuracy of atrial tachyarrhythmia detection in implantable devices with arrhythmia therapies.
        Pacing Clin Electrophysiol. 2004; 27: 983-992
        • Passman R.S.
        • Weinberg K.M.
        • Freher M.
        • Denes P.
        • Schaechter A.
        • Goldberger J.J.
        • Kadish A.H.
        Accuracy of mode switch algorithms for detection of atrial tachyarrhythmias.
        J Cardiovasc Electrophysiol. 2004; 15: 773-777

      Linked Article

      • Subclinical atrial fibrillation: The significance of progression to longer episodes
        Heart RhythmVol. 15Issue 3
        • Preview
          Subclinical atrial fibrillation (SCAF) is a term used to describe short-lasting (minutes to hours), asymptomatic atrial fibrillation (AF) detected by long-term continuous monitoring, typically using an implanted pacemaker, defibrillator, or cardiac monitor.1 Both the TRENDS (The Relationship Between Daily Atrial Tachyarrhythmia Burden from Implantable Device Diagnostics and Stroke Risk) and ASSERT (Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial) studies have shown that SCAF is associated with an increased risk of stroke.
        • Full-Text
        • PDF