Fibrilacion Auricular Subclinica

FIBRILACION ATRIAL SUBCLINICA EN
PACIENTES PORTADORES DE
DISPOSITIVOS
MR CARDIOLOGÍA
MAICOL AUGUSTO CORTEZ SANDOVAL
Introduccion
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.
Circulation. 2019;140:00–00. DOI: 10.1161/CIR.0000000000000740

Dr. Maicol A. Cortez sandoval
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
The term SCAF has been FA silente

used to describe atrial (asintomática): FA
arrhythmia episodes documentada en
detected by cardiac ausencia de síntomas.
implanted electronic
device

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

Detección de eventos por los dispositivos
*Longer detection duration may reduce false

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

Prevalencia de fibrilacion atrial subclinica
La prevalencia de FA subclinica en
pacientes con CIED son reportados en
un rango desde 30-60%
Circulation. 2019;140:00–00.
Fa subclinica evoluciona a FA clínica ?
FA SUBCLINICA FA CLINICA
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.
*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

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

CHADS2 y FA subclinica
TRENDS study.
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

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
Another recent study showed that short

AT/AF episodes (<15–20 seconds) were
not associated with clinical events,
Circulation. 2019;140:00–00. DOI: 10.1161/CIR.0000000000000740

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
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 .
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.
N Engl J Med 2012;366:120-9.
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
for SCAF>6min 39%,>6h 19%, and>24h 11%.
European Heart Journal (2017) 0, 1–6

doi:10.1093/eurheartj/ehx042
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

Subclinical Atrial Fibrillation and the Risk of Stroke
Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial ASSERT
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

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
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.
Age ≥ 65 NO FA
Inclusion
Criteria
CHA2DS2-VASc score ≥
2 O SAOS Or BMI > 30
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

DDAT (≥5 minutes
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

New-Onset Device-Detected Atrial Tachyarrhythmia A Meta-
Analysis
Prolonged duration of DDAT (≥5 minutes) is associated with higher risk of TE compared with use of lower
diagnostic threshold (<1 minute).
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

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.
156(83%) patients had

no positive AHRE en 120
day.
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
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
Europace (2017) 19, 1556–1578
*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

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
CHA2DS2-VASc -AHRE
*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
Circulation. 2019;140:00–00.
FA subclinica y hospitalizaciones por falla cardiaca
The ASSERT study

enrolled 2,580
participants age >65
years
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

AHRE y eventos cardiovasculares adversos mayores
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
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

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
CHA2DS2-VASc = Anticuagulacion
CHA2DS2-VASc -AHRE
CHA2DS2-VASc = Anticuagulacion ?
Circulation.2018;137:217-218
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

Rationale and design of the Apixaban for the Reduction of Thrombo-Embolism
in Patients With Device-Detected Sub-Clinical Atrial Fibrillation (ARTESiA) trial
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
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

Anticuagulación
2021
2022

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

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

Fibrilacion Auricular Subclinica

Cargado por

Copyright:

Formatos disponibles

Fibrilacion Auricular Subclinica

Cargado por

Información del documento

Derechos de autor

Formatos disponibles

Compartir este documento

Compartir o incrustar documentos

Opciones para compartir

¿Le pareció útil este documento?

¿Este contenido es inapropiado?

Copyright:

Formatos disponibles

Fibrilacion Auricular Subclinica

Cargado por

Copyright:

Formatos disponibles

FIBRILACION ATRIAL SUBCLINICA EN

La fibrilacion auricular es una pandemia cardiovascular con una compleja

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.

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

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

The term SCAF has been FA silente

Dr. Maicol A. Cortez sandoval

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

*Longer detection duration may reduce false

far- field R-wave sensing

2.Clinical Research in Cardiology (2020) 109:409–416

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

Ziegler, P. D., G. (2012). Detection of Previously Undiagnosed Atrial Fibrillation in Patients

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

1.. Subclinical Atrial Fibrillation and the Risk of Stroke. New

2. Gage, (2001). Validation of Clinical Classification

Dr. Maicol A. Cortez sandoval

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

Another recent study showed that short

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

Primary Outcome Measures :

Secondary Outcome Measures :

In pacemaker patients only the primary indication for pacing is

Dr. Maicol A. Cortez sandoval

European Heart Journal (2017) 0, 1–6

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

More recently, an analysis from ASSERT suggest a substantial increase in

European Heart Journal (2017) 0, 1–6 doi:10.1093/eurheartj/ehx042

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

Belkin,. (2018). Incidence and Clinical Significance of New-

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

he observation that in ASSERT many strokes were not

Circulation. 2019;140:00–00. DOI:

Dr. Maicol A. Cortez sandoval

156(83%) patients had

Europace (2017) 19, 1556–1578

*Daoud, E. G. (2011). Temporal relationship of atrial tachyarrhythmias, cerebrovascular

Dr. Maicol A. Cortez sandoval

*However, although not all strokes are

*Daoud, E. G. (2011). Temporal relationship of atrial tachyarrhythmias,

The ASSERT study

Dr. Maicol A. Cortez sandoval

developing AHREs show a

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval

Dr. Maicol A. Cortez sandoval