Practice Update: Cardiology

EDITOR’S PICKS 7

patients had a prior history of stroke or transient ischemic attack. The endpoint was device-detected AF for ≥5 minutes. AF was detected at a rate of 34.4% per year, with a mean time from ILR insertion to detection of 5.1±5.5 months. Subclinical or device-detected AF occurred before clin- ical diagnosis of the arrhythmia in 69% of the patients at a median of 82.5 days ear- lier. In patients with a history of a cerebral ischemic event, AF detection rates were higher at 39.4% per year. Among secondary endpoints, 4 patients had an ischemic stroke during follow-up, of whom none had detected AF. One hemor- rhagic stroke developed in a patient with detected AF who was started on anticoag- ulation. Of the 90 patients with AF, 60 were started on anticoagulation, in 45 of whom the decision was made from the device-de- tected arrhythmia. This study has several important clinical findings. First, the data continue to support the use of long-termmonitors for AF detec- tion in patients with a cryptogenic stroke. The average time required to detect (>5 months) highlights the utility of long-term implantable monitors compared with ambu- latory monitors. Current studies such as Apixaban for Treatment of Embolic Stroke of Undetermined Source (ATTICUS) and Rivaroxaban Versus Aspirin in Second- ary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined

of these data in addition to other data from CIED trials that show lack of consistent tem- poral correlation between AF incidence and stroke, 5,6 we must question the tra- ditional hypothesis of the role of AF and stroke, and, as a consequence, how we will reduce stroke events in the future. References 1. Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation 2014;129(8):837-847. 2. Brunner KJ, Bunch TJ, Mullin CM, et al. Clinical predictors of risk for atrial fibrillation: implications for diagnosis and monitoring. Mayo Clin Proc 2014;89(11):1498-1505. 3. Sanna T, Diener HC, Passman RSet al. Cryptogenic stroke and underlying atrial fibrillation. N Eng J Med 2014;370(26):2478-2486. 4. Healey JS, Alings M, Ha AC, et al. Subclinical Atrial Fibrillation in Older Patients [published online August 4, 2017]. Circulation doi: 10.1161/ CIRCULATIONAHA.117.028845. [Epub ahead of print] 5. Brambatti M, Connolly SJ, Gold MR, et al. Temporal relationship between subclinical atrial fibrillation and embolic events. Circulation 2014;129(21):2094-2099. 6. Martin DT, Bersohn MM, Waldo AL, et al. Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients

Source (NAVIGATE ESUS) will evaluate if empiric anticoagulation, given the very high expected rates of subclinical AF in cryptogenic stroke patients, will lower sec- ondary stroke rates. Second, this study demonstrates the value of ILRs in higher-risk patients for AF with a yield of arrhythmia detection in approx- imately 1 in 3. What remains to be known is if this early detection can lead to tar- geted therapies that will significantly impact outcomes compared with conventional approaches based on clinical AF diagnosis. Third, this study highlights the lack of sen- sitivity in AF diagnosis based upon patient symptoms and routine clinical investigation. Finally, this study continues to prompt the question, is AF a marker of a systemic vas- cular disease state or a focal risk factor of the atrium? The answer to this question is critical as we consider pill-in-the-pocket anticoagulation, left atrial appendage closure devices, and rhythm control approaches to lower stroke risk. If AF is a focal disease of the left atrium, then these approaches should lower stroke risk. How- ever, if AF is a risk marker of severity of a systemic disease state, then anticoagula- tion strategies will be needed long-term and stroke risk reduction will be depend- ent on treatment and modification of the processes driving the systemic disease. In this study of patients at higher risk for AF with ILRs, the few strokes that did occur were independent of AF. In consideration

with implanted defibrillator and cardiac resynchronization devices. Eur Heart J 2015;36(26):1660-1668.

Dr Bunch is Medical Director of Electrophysiology for Intermountain Healthcare, Intermountain Heart Institute,

Intermountain Medical Center, Murray, Utah.

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VOL. 2 • NO. 2 • 2017