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N Engl J Med. 2012 Jan 12;366(2):120-9. doi: 10.1056/NEJMoa1105575.

Subclinical atrial fibrillation and the risk of stroke.

Collaborators (328)

Connolly S, Bailleul C, Capucci A, Carlson M, Fain E, Healey JS, Hohnloser S, Israel C, Lau CP, Morillo C, Themeles E, Van Gelder I, Crystal E, Armagenian L, Blomstrom P, Brandes A, Connolly S, Costantini O, Dahl T, Divakaramenon S, Eikelboom J, Fodor G, Goto S, Guimaraes HP, Halon D, Hartikainen J, Healey JS, Hohnloser S, Hussan M, Israel C, Kaufman E, Keltai M, Kristensen KS, Lau C, Lonn E, Mairesse GH, Morillo C, Nair G, Nayak H, Oldgren J, Onalan O, Parkash R, Peker A, Sandhu R, Simmers T, Swissa M, Thibault B, Turazza F, Zimlichman R, Dorian P, Ellenbogen K, Roberts RS, Andrews J, Bourgeois C, Ecker C, Bouchez D, Boulogne E, Daems K, Willems V, Aasen-Johnston L, Biggs T, Blankensteiner J, Lidén Mascher K, Palo M, Bourguiba A, Razani M, Bodden C, Huemmer A, Scheiner J, Yakzan M, Lau E, Lau S, Yim L, Day K, Watson D, Tkach Y, Gazzola C, Guidotto T, Silvestri P, Ichishima Y, Manabe M, Hubregtse M, Silva C, Garcia de Rivera R, Llorente E, Santamaria Rebollo P, Castaneda M, Dalal Y, Oza A, Saberi L, Shkurovich S, Djuric A, Napoleoni R, Pogue J, Themeles E, Yang S, Mond HG, Benzer W, Bitschnau R, Formanek M, Mlczoch J, Teubl A, Trinks S, Weber H, Zweng A, El Allaf D, Leroy JL, Mairesse GH, Ayala-Paredes F, Beaudoin J, Becker G, Birnie DH, Blier L, Cameron DA, Crystal E, Divakaramenon S, Guerra PG, Houde G, Janmohamed A, Khaykin Y, Kus T, Lai C, Lashevsky I, Lau C, Leather R, Marchand F, Nair G, Nath A, Nigro F, Ottinger B, Parkash R, Ribas S, Sapp JL, Shearer B, Sinha SN, Sterns L, Sturmer ML, Talajic M, Tang AS, Tang A, Thibault B, Tung S, Van Kieu C, Winger K, Brandes A, Hoejberg S, Karlsen M, Pedersen OD, Salo TM, Cransac F, Cung TT, Davy JM, Brachmann J, Duray GZ, Hansen C, Heuer HH, Himmrich E, Holt SH, Israel CW, Karolyi L, Kloppe AK, Lawo TL, Lemke BL, Mijic DM, Mügge A, Neubauer H, Neuzner J, Schade A, Schmitt J, Schumacher B, Seidl K, Spitzer SG, Cokkinos DV, Maounis TN, Poulos GD, Chan NY, Fan KY, Lau CP, Leung SK, Siu DC, Tam LW, Tsang CY, Tse HF, McFadden S, McGrath F, Sheahan R, Antonelli D, Freedberg NA, Geist M, Glikson M, Gurevitz O, Halfin Z, Katz A, Khalameizer V, Kuznitz H, Luria D, Militianu A, Steinvil A, Strasberg B, Swissa M, Tarchitzki D, Viskin S, Zeltser D, Carreras G, Coppola A, Eligiato M, Liberti F, Lisi F, Muto C, Pelargonio G, Pratola C, Rauhe WG, Scipione P, Sisto F, Speca G, Toselli T, Tuccillo B, Villani GQ, Abe H, Kanda G, Kohno R, Manaka T, Mizutani K, Nagatomo T, Noro M, Okajima K, Sakata T, Shoda M, Sugi K, Yagishita D, Kim YN, Khelae S, Omar R, Atar D, Hegrenæs L, Nesvold A, Alves MA, Cunha PM, Francisco A, Madeira FJ, Martins VP, Morais CM, Rebelo AM, Sanfins VM, Silva FJ, Torres AM, Cazorla M, Gusi G, Martín A, Martínez A, Matiello ML, Mont L, Frick E, Jakobsson S, Lönnerholm S, Österberg BL, Chen WJ, Liu YB, Breuls NP, Hazeleger R, Scholten MF, Tuininga YS, Van Gelder IC, Abdullah EE, Abi-Samra F, Ahern TS, Akula DN, Athill C, Baer ML, Barber MJ, Belott P, Birgersdotter-Green UM, Brodine WN, Browne KF, Cardona F, Caruso AC, Ciuffo AC, Cole CR, Conard L, Cooper JM, Costantini O, Costeas CA, Croitoru M, Curtis GP, Deering TF, Donahue T, Edwards TS, Fu EU, Glenn JL, Goodman JS, Grogan EW, Gursoy AS, Hughes DG, Jaffe BD, Jazayeri MR, Kall JG, Kaplan AJ, Kaufman ES, Kavesh NG, Khan MN, Kushner JA, Lan DZ, Lee JK, Leman RB, Liu ZG, Machell CH, Nath S, Nayak HM, Ngo MM, Nichols AJ, Nsah EN, Pritchard T, Roelke M, Rogers JD, Sandler MJ, Schuger CD, Sheppard RC, Sholevar DP, Silva EA, Silver MT, Sklar J, Strobel JS, Strunk BL, Sturdivant JL, Telfer EA, Tran AT, VanHamersveld DD, Villareal RP.

Author information

1
Population Health Research Institute, McMaster University, Hamilton, ON, Canada.

Abstract

BACKGROUND:

One quarter of strokes are of unknown cause, and subclinical atrial fibrillation may be a common etiologic factor. Pacemakers can detect subclinical episodes of rapid atrial rate, which correlate with electrocardiographically documented atrial fibrillation. We evaluated whether subclinical episodes of rapid atrial rate detected by implanted devices were associated with an increased risk of ischemic stroke in patients who did not have other evidence of atrial fibrillation.

METHODS:

We enrolled 2580 patients, 65 years of age or older, with hypertension and no history of atrial fibrillation, in whom a pacemaker or defibrillator had recently been implanted. We monitored the patients for 3 months to detect subclinical atrial tachyarrhythmias (episodes of atrial rate >190 beats per minute for more than 6 minutes) and followed them for a mean of 2.5 years for the primary outcome of ischemic stroke or systemic embolism. Patients with pacemakers were randomly assigned to receive or not to receive continuous atrial overdrive pacing.

RESULTS:

By 3 months, subclinical atrial tachyarrhythmias detected by implanted devices had occurred in 261 patients (10.1%). Subclinical atrial tachyarrhythmias were associated with an increased risk of clinical atrial fibrillation (hazard ratio, 5.56; 95% confidence interval [CI], 3.78 to 8.17; P<0.001) and of ischemic stroke or systemic embolism (hazard ratio, 2.49; 95% CI, 1.28 to 4.85; P=0.007). Of 51 patients who had a primary outcome event, 11 had had subclinical atrial tachyarrhythmias detected by 3 months, and none had had clinical atrial fibrillation by 3 months. The population attributable risk of stroke or systemic embolism associated with subclinical atrial tachyarrhythmias was 13%. Subclinical atrial tachyarrhythmias remained predictive of the primary outcome after adjustment for predictors of stroke (hazard ratio, 2.50; 95% CI, 1.28 to 4.89; P=0.008). Continuous atrial overdrive pacing did not prevent atrial fibrillation.

CONCLUSIONS:

Subclinical atrial tachyarrhythmias, without clinical atrial fibrillation, occurred frequently in patients with pacemakers and were associated with a significantly increased risk of ischemic stroke or systemic embolism. (Funded by St. Jude Medical; ASSERT ClinicalTrials.gov number, NCT00256152.).

PMID:
22236222
DOI:
10.1056/NEJMoa1105575
[Indexed for MEDLINE]
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