DR. MAICOL AUGUSTO CORTEZ SANDOVAL/Fibrilacion auricular subclinica

MR CARDIOLOGÍA
MAICOL AUGUSTO CORTEZ SANDOVAL
FIBRILACION ATRIAL SUBCLINICA EN
PACIENTES PORTADORES DE
DISPOSITIVOS

Dr. Maicol A. Cortez sandoval
Introduccion
Circulation. 2019;140:00–00. DOI: 10.1161/CIR.0000000000000740
La fibrilacion auricular es una pandemia cardiovascular con una compleja
patofisiologia.

Afecta a 33 millones de personas en el mundo.

En europa y EEUU 1:4 sufrirá FA.

Contribuye significativamente un aumento en la morbilidad y mortalidad.

30-40% DE ACV isquemicos es por FA.

10-40% de FA son hospitalizados cada año.

Epidemiologia
Chung, M. K.Atrial Fibrillation. Journal of the American College of Cardiology, 75(14), 1689–1713. doi:10.1016/j.jacc.2020.02.025

Factores de riesgo de la fibrilacion auricular
Chung, M. K.Atrial Fibrillation. Journal of the American College of Cardiology, 75(14), 1689–1713. doi:10.1016/j.jacc.2020.02.025

ECG monitoring in patients with cryptogenic stroke
Gladstone, D. J., 2014. Atrial Fibrillation in Patients with Cryptogenic Stroke. New England Journal of Medicine, 370(26), 2467–2477. doi:10.1056/NEJMoa1311376

Atrial
ﬁbrillation
subclinic
al in
divice ?

Definición:
Circulation. 2019;140:00–00.
*Fibrillaton auricular subclínico (FA): episodios auriculares de alta frecuencia (> 6 minutos y <24
horas) con falta de síntomas correlacionados en pacientes con dispositivos electrónicos
implantables cardíacos, detectados con monitorización continua de ECG (intracardíaco) y sin
diagnóstico previo (ECG o Monitoreo Holter) de la FA.
*Europace (2017) 19, 1556–1578

Definición
AHRE: FA SUBCLINICA FA: FA CLÍNICA
FA silente
(asintomática): FA
documentada en
ausencia de síntomas.
The term SCAF has been
used to describe atrial
arrhythmia episodes
detected by cardiac
implanted electronic
device

AHRE ES UN PRECURSOR DE FA ?
Clinical Research in Cardiology (2020) 109:409–416
Atrial high rate episodes
(AHREs), also termed, subclinical
atrial tachyarrhythmias or
subclinical atrial ﬁbrillation (AF)
are an important cardiovascular
condition.

Detección de eventos por los dispositivos
-Subcutaneous ICMs yield AF detection, primarily with the use of
R-R irregularity algorithms
*Longer detection duration may reduce false
positives in CIEDs
- Circulation. 2019;140:00–00. DOI
*The CIEDs’ AHRE algorithm has a high sensitivity for detection of
AF, ranging from 94 to 100%
2.Clinical Research in Cardiology (2020) 109:409–416
(ASSERT) 6000 AHREs (190 beats per minute for more
than 6 min) and discovered that 17.3% were false
positives However, the rate of false positives was
reduced to 3.3% when using a longer threshold of 6 h
for AHRE.
far- ﬁeld R-wave sensing

Prevalencia de fibrilacion atrial subclinica
Circulation. 2019;140:00–00.
La prevalencia de FA subclinica en
pacientes con CIED son reportados en
un rango desde 30-60%

Fa subclinica evoluciona a FA clínica ?
FA SUBCLINICA FA CLINICA
*AHRE detected by pacemakers in patients with SND identify patients have a 5.9 times as likely to develop clinical atrial
ﬁbrillation as similar patients without AHRE(MOST (n=2010) during the 2.25-year median follow-up)
*Glotzer, T. V. (2003). 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, 107(12), 1614–1619. doi:10.1161/01.CIR.0000057981.70380.45
Data from ASSERT (n=2580) showed that SCAF in the ﬁrst 3 months (n=216) was associated with a 5.6-fold higher
hazard of clinical AF during the 2.5-year mean follow-up.
N Engl J Med 2012;366:120-9.

Evolución de episodio inicial—> episodio >23h
Circulation. 2019;140:00–00.

CHADS2 y FA subclinica
Ziegler, P. D., G. (2012). Detection of Previously Undiagnosed Atrial Fibrillation in Patients
With Stroke Risk Factors and Usefulness of Continuous Monitoring in Primary Stroke
Prevention. The American Journal of Cardiology, 110(9), 1309–1314. doi:10.1016/
j.amjcard.2012.06.034
TRENDS study.

RIESGO DE

TROMBOEMBOLISMO

DIFERENTE PERFIL DE RIESGO ACV ISQUEMICO FA CLÍNICA
Y FA SUBCLINICA
1.. Subclinical Atrial Fibrillation and the Risk of Stroke. New
England Journal of Medicine, 366(2), 120–129. doi:10.1056/
NEJMoa1105575
2. Gage, (2001). Validation of Clinical Classiﬁcation
Schemes for Predicting Stroke. JAMA, 285(22), 2864.
doi:10.1001/jama.285.22.2864

Riesgo de tromboembolismo
Clinical Research in Cardiology (2020) 109:409–416

Hazard ratio (HR) for thromboembolism
Circulation. 2019;140:00–00. DOI: 10.1161/CIR.0000000000000740
Another recent study showed that short
AT/AF episodes (<15–20 seconds) were
not associated with clinical events,

Inclusion Criteria
Age ≥ 65 years
History of hypertension requiring pharmacological therapy (≥ 4
weeks of therapy).
Recent (< 8 weeks) St. Jude Medical Inc. pacemaker, ICD implant
In pacemaker patients only the primary indication for pacing is
sinus or AV node disease.
Primary Outcome Measures :
Composite of ischemic stroke & Non-CNS systemic embolism Symptomatic
Secondary Outcome Measures :
Myocardial infarction [MI], Vascular death Composite of stroke, MI or
vascular death .
N Engl J Med 2012;366:120-9.
Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the
Atrial Fibrillation Reduction Atrial Pacing Trial ASSERT
episodes of atrial rate >190 x` > 6 minutes)
and followed them for a mean of 2.5 years
Healey, J. S., Connolly, S. J., Gold, M. R., Israel, C. W., Van Gelder, I. C., Capucci, A., … Hohnloser, S. H. (2012). Subclinical Atrial Fibrillation and the Risk of Stroke. New England Journal of Medicine, 366(2), 120–129. doi:10.1056/NEJMoa1105575

Duration of device- detected subclinical atrial fibrillation
ASSERT I
Van Gelder, I. C.. (2017). Duration of device-detected subclinical atrial ﬁbrillation and occurrence of stroke in ASSERT. European Heart Journal, 38(17), 1339–1344. doi:10.1093/eurheartj/ehx042
European Heart Journal (2017) 0, 1–6
doi:10.1093/eurheartj/ehx042
for SCAF>6min 39%,>6h 19%, and>24h 11%.

Subclinical Atrial Fibrillation and the Risk of Stroke
Healey, J. S.(2012). Subclinical Atrial Fibrillation and the Risk of Stroke. New England Journal of Medicine, 366(2), 120–129. doi:10.1056/NEJMoa1105575
Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial ASSERT

Duración de FA subclinica y Evento isquemico
More recently, an analysis from ASSERT suggest a substantial increase in
the absolute risk of stroke or systemic embolism when patients developed
an episode of SCAF lasting at least 24 continuous hours
Van Gelder, I. C., Healey, J. S., Crijns, H. J. G. M., Wang, J., Hohnloser, S. H., Gold, M. R., … Connolly, S. J. (2017). Duration of device-detected
subclinical atrial ﬁbrillation and occurrence of stroke in ASSERT. European Heart Journal, 38(17), 1339–1344. doi:10.1093/eurheartj/ehx042
European Heart Journal (2017) 0, 1–6 doi:10.1093/eurheartj/ehx042

ASSERT II
Inclusion
Criteria
Primary Objectives:
1. To determine the rate of detection of sub-clinical atrial AF (≥ 5 minutes)
within an average of 12 months following implant of the St. Jude Medical
Conﬁrm® Implantable.
CHA2DS2-VASc score ≥
2 O SAOS Or BMI > 30
Age ≥ 65 NO FA
LA volume ≥ 58 ml or LA
diameter of ≥ 4.4 cm) Or NT-
ProBNP ≥ 290 pg/mL
(detection rate 34.4% per year; 95% conﬁdence interval [CI], 27.7-42.3%

ASSERT II
Inclusion
Criteria
Healey, J. Connolly, S. J. (2017). Subclinical Atrial Fibrillation in Older Patients. Circulation, 136(14), 1276–1283. doi:10.1161/circulationaha.117.028845

Belkin,. (2018). Incidence and Clinical Signiﬁcance of New-
Onset Device-Detected Atrial Tachyarrhythmia. Circulation:
Arrhythmia and Electrophysiology, 11(3), e005393.
doi:10.1161/CIRCEP.117.005393
DDAT (≥5 minutes

New-Onset Device-Detected Atrial Tachyarrhythmia A Meta-
Analysis
Belkin,. (2018). Incidence and Clinical Signiﬁcance of New-Onset Device-Detected Atrial Tachyarrhythmia. Circulation: Arrhythmia and Electrophysiology, 11(3), e005393. doi:10.1161/CIRCEP.117.005393
Prolonged duration of DDAT (≥5 minutes) is associated with higher risk of TE compared with use of lower
diagnostic threshold (<1 minute).

Los ACV isquemicos están inmediatamente precedido de
episodios de FA.
he observation that in ASSERT many strokes were not
immediately preceded by AF episodes
Circulation. 2019;140:00–00. DOI:
10.1161/CIR.0000000000000740

Los ACV isquemicos están inmediatamente precedido de
episodios de FA.
Turakhia, M. (2015). Atrial Fibrillation Burden and Short-Term Risk of Stroke. Circulation: Arrhythmia
and Electrophysiology, 8(5), 1040–1047. doi:10.1161/circep.114.003057
156(83%) patients had
no positive AHRE en 120
day.

Evaluación de CIED mediante monitoreo remoto
Turakhia, M. (2015). Atrial Fibrillation Burden and Short-Term Risk of Stroke. Circulation: Arrhythmia and Electrophysiology, 8(5), 1040–1047. doi:10.1161/circep.114.003057

strokes were immediately preceded by AF episodes
Turakhia, M. (2015). Atrial Fibrillation Burden and Short-Term Risk of Stroke. Circulation: Arrhythmia and
Electrophysiology, 8(5), 1040–1047. doi:10.1161/circep.114.003057

Relacion de temporalidad FASC-ET
*Daoud, E. G. (2011). Temporal relationship of atrial tachyarrhythmias, cerebrovascular
events, and systemic emboli based on stored device data: A subgroup analysis of
TRENDS. Heart Rhythm, 8(9), 1416–1423. doi:10.1016/j.hrthm.2011.04.022
Europace (2017) 19, 1556–1578

FA subclinica es un marcador de riesgo o causa directa
*However, although not all strokes are
cardioembolic and not all thrombi are
directly related to ATRIAL FIBRILLATION
*Daoud, E. G. (2011). Temporal relationship of atrial tachyarrhythmias,
cerebrovascular events, and systemic emboli based on stored device data: A
subgroup analysis of TRENDS. Heart Rhythm, 8(9), 1416–1423. doi:10.1016/
j.hrthm.2011.04.022
CHA2DS2-VASc -AHRE
Circulation. 2019;140:00–00.

FA subclinica y hospitalizaciones por falla cardiaca
Wong, J. A. (2018). Progression of Device-Detected Subclinical Atrial Fibrillation and the Risk of Heart
Failure. Journal of the American College of Cardiology, 71(23), 2603–2611. doi:10.1016/j.jacc.2018.03.519
The ASSERT study
enrolled 2,580
participants age >65
years

AHRE y eventos cardiovasculares adversos mayores
Pastori, D., (2019). Atrial high-rate episodes and risk of major adverse cardiovascular
events in patients with cardiac implantable electronic devices. Clinical Research in
Cardiology. doi:10.1007/s00392-019-01493-z
852 patients undergoing CIEDs implantation.
Primary outcome : MACEs occurring after AHREs ≥ 5 min.
AHRE ( > 175 bpm and lasting ≥ 5 min.)
developing AHREs show a
signiﬁcant risk for MACE

TRATAMIENTO

European Heart Journal, 37(38), 2893–2962.

Tratamiento
January, C. T. (2019). 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. doi:10.1161/CIR.0000000000000665

Tratamiento
Camm, A. J., (2016). Atrial high-rate episodes and stroke prevention. EP Europace, 19(2), 169–179. doi:10.1093/europace/euw279

Tratamiento
Andrade, J. G.(2018). 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation.
Canadian Journal of Cardiology, 34(11), 1371–1392. doi:10.1016/j.cjca.2018.08.026

Tratamiento
Europace (2017) 19, 1556–1578

Tratamiento
Circulation. 2019;140:00–00. DOI:
10.1161/CIR.0000000000000740

Cuando anticuagular
Circulation.2018;137:217-218
CHA2DS2-VASc
CHA2DS2-VASc
=
=
Anticuagulacion
Anticuagulacion ?
Van Gelder, I. C., Healey, J. S., Crijns, H. J. G. M., Wang, J., Hohnloser, S. H., Gold, M. R., … Connolly, S. J. (2017). Duration of device-detected subclinical atrial ﬁbrillation and occurrence of stroke in ASSERT. European Heart Journal, 38(17), 1339–1344. doi:10.1093/eurheartj/ehx042
CHA2DS2-VASc -AHRE

Rationale and design of the Apixaban for the Reduction of Thrombo-Embolism
in Patients With Device-Detected Sub-Clinical Atrial Fibrillation (ARTESiA) trial
Lopes, R. D. (2017). Rationale and design of the Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation (ARTESiA) trial. American Heart Journal, 189, 137–145. doi:10.1016/j.ahj.2017.04.008
1. Permanent pacemaker or deﬁbrillator with atrial lead (with or without resynchronization) or a single-chamber device with an AF detection algorithm similar to those used in implantable loop
recorders, or insertable cardiac monitor capable of detecting SCAF

2. 2. At least one episode of device-detected SCAF ≥6 min in duration (atrial rate N 175/min if an atrial lead is present), but no single episode N24 h in duration at any time before enrollment.
SCAF requires at least one episode of electrogram conﬁrmation (unless ≥6 h in duration)

3. Age ≥ 55 y

4. Risk factors for stroke (any of the following):

• Previous stroke, TIA, or SE

• Age ≥75 y

• Age 65-74 y + at least 2 risk factors ⁎

• 55-64 years old + at least 3 risk factors

Anticuagulación
2021
2022

PARA LA ANTICUAGULACION
INDIVIDUALIZAR
CARGA DE FA: DURACIÓN
RIESGO HEMORRAGICO
PREFERENCIA DEL PACIENTE
REVISAR ELECTROGRAMA
RIESGO EMBOLICO —> CHA2DSVAS2C

Take home message
La FA subclinica es frecuente en portadores de dispositivos la
prevalencia son reportados en un rango desde 30-60% y un
14%/año.

Incidencia ictus isquemicos es 1.89 por 100 personas/ año (HR=
2.88)

FA Subclinica provee una oportunidad para disminuir el riesgo
isquemico.

Evaluar la FA subclinica y no esperar que se convierta en FA
clinica para iniciar tratamito.

Gracias

DR. MAICOL AUGUSTO CORTEZ SANDOVAL/Fibrilacion auricular subclinica

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