Atrial Fibrillation Progression in Patients with Device-Detected Subclinical Atrial Fibrillation: Insights from the ARTESiA Trial.
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abstract
BACKGROUND: The ARTESiA trial enrolled patients with subclinical atrial fibrillation (SCAF) lasting < 24 hours. OBJECTIVE AND METHODS: We assessed the association of SCAF progression to clinical atrial fibrillation (AF) or SCAF > 24 hours with adverse outcomes and predictors of SCAF progression. RESULTS: During follow-up (4.1 ± 1.7 years), SCAF progressed in 1250 (31.2%) of 4,012 patients, at a rate of 9.3% per patient-year. SCAF progression was associated with adverse outcomes, with the following hazard ratios (HR) and 95% CI: all-cause death: 2.12 (1.83-2.45], heart failure death: 4.81 (3.19-7.27) and arrhythmic death: 2.62 (1.58-4.35). The rate of stroke/systemic embolism in patients who remained on blinded aspirin therapy after SCAF progression was 1.42% per patient-year. If one limits the definition of progression to SCAF lasting > 24 hours, the rate was 1.75% per patient-year. Baseline variables modestly predicted SCAF progression (C statistic = 0.59, 95% CI 0.57-0.61), including: age [HR 1.02 (1.01-1.03) per year], male sex [HR 1.30 (1.14-1.47)], history of heart failure [HR 1.28 (1.13-1.46)], diabetes mellitus [HR 1.18 (1.04-1.34)], left atrial diameter > 4.1 cm [HR 1.28 (1.08-1.52)], and baseline duration of longest SCAF >1hr [HR 1.59 (1.42-1.79)]. CONCLUSIONS: SCAF progression occurred in over 9% per year and was associated with a doubling of the risk of all-cause mortality, driven by an increase in both heart failure-related and arrhythmic deaths. Patients who remained on aspirin following SCAF progression had an annual rate of stroke/systemic embolism of 1.42%, which is higher than the threshold currently proposed for OAC prophylaxis.
