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Cardiac implantable electronic device-detected atrial fibrillation—“To anticoagulate or not to anticoagulate, that is the question”: The noble or ignoble choice?

Published:November 09, 2020DOI:https://doi.org/10.1016/j.hrthm.2020.11.007
      Atrial fibrillation (AF) detected during interrogation of a cardiovascular implantable electronic device (CIED) is a common event,
      • Ziegler P.D.
      • Glotzer T.V.
      • Daoud E.G.
      • et al.
      Incidence of newly detected atrial arrhythmias via implantable devices in patients with a prior history of thromboembolic events.
      with available studies suggesting that it is associated with an increased risk of stroke.
      • Glotzer T.V.
      • Daoud E.G.
      • Wyse D.G.
      • et al.
      The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study.
      ,
      • Healey J.S.
      • Connolly S.J.
      • Gold M.R.
      • et al.
      ASSERT Investigators. Subclinical atrial fibrillation and the risk of stroke.
      While current guidelines recommend oral anticoagulant (OAC) therapy for patients with AF and an elevated CHA2DS2-VASc score,
      • January C.T.
      • Wann L.S.
      • Calkins H.
      • et al.
      2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons.
      controversy exists about whether the various components of CIED-detected AF (eg, duration, burden, and CHA2DS2-VASc score) predict stroke and, if effective as predictors, which characteristics best define that risk.
      • Mahajan R.
      • Perera T.
      • Elliott A.D.
      • et al.
      Subclinical device-detected atrial fibrillation and stroke risk: a systematic review and meta-analysis.
      As a result of this uncertainty, physicians concerned about thromboembolic risk often recommend OAC therapy for patients with CIED-detected AF. This was demonstrated in Predicting Determinants of Atrial Fibrillation or Flutter for Therapy Elucidation in Patients at Risk for Thromboembolic Events (PREDATE AF) Study and REVEAL AF studies, in which, respectively, 76.4% and 56.3% of patients meeting predefined duration criteria for new-onset CIED-detected AF were prescribed anticoagulants.
      • Nasir J.M.
      • Pomeroy W.
      • Marler A.
      • et al.
      Predicting determinants of atrial fibrillation or flutter for therapy elucidation in patients at risk for thromboembolic events (PREDATE AF) study.
      ,
      • Reiffel J.A.
      • Verma A.
      • Kowey P.R.
      • et al.
      Incidence of previously undiagnosed atrial fibrillation using insertable cardiac monitors in a high-risk population: the REVEAL AF study.
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