Management of Device Detected Subclinical Atrial Fibrillation

Abstract

Abstract Purpose of Review Whilst the management of clinically apparent atrial fibrillation (AF) is well-described and evidenced, the same is not true for subclinical atrial fibrillation (SCAF) and atrial high rate episodes (AHRE). In this review article we discuss the management of device-detected AHRE/SCAF in light of recent major trials and meta-analyses. Recent Findings Anticoagulation in AHRE/SCAF reduces thromboembolic risk but causes an increase in bleeding events. Of note, ischaemic stroke risk in untreated AHRE/SCAF has been observed to be lesser than that of untreated clinically evident AF. With regard to reduction of AHRE/SCAF prevalence or burden, increased physical activity has been associated with reduced AHRE/SCAF incidence in a dose-dependent manner. There exists mixed evidence for both angiotensin 2 inhibition therapy and statin therapy in the prevention of AHRE/SCAF in studies with smaller populations. Ongoing studies are assessing the impact of sodium-glucose cotransporter-2 inhibition on AHRE/SCAF. Although there is no evidence for atrial overdrive pacing in preventing AHRE/SCAF, limited evidence suggests pacing lead position and reducing ventricular pacing may minimise AHRE/SCAF. Summary The identification of AHRE/SCAF poses unanswered questions regarding treatment. The benefit of anticoagulation in reducing ischaemic stroke is lesser than that seen in clinical AF. As such, anticoagulation decisions in AHRE/SCAF should take into consideration individual bleeding risk, thromboembolic risk, and arrythmia burden. Management of co-morbidities and physical activity show promise in reducing AHRE/SCAF. Further study is required to investigate the impact of various pharmacologic interventions and pacing considerations on the reduction of AHRE/SCAF.