Treatment of Subclinical Atrial Fibrillation: Does One Plus One Always Equal Two?

Abstract

Atrial fibrillation (AF) is the most common pathological arrhythmia observed in clinical practice and it is associated with stroke, heart failure, and increased mortality. Multiple pivotal, randomized trials established the role of anticoagulation to reduce the risk of stroke among patients with AF with an elevated risk profile, as assessed by the CHADS2 or CHA2DS2-VASc scoring systems. As such, anticoagulation with warfarin or novel oral anticoagulants is a class I indication in the treatment of patients with AF by all major societies, even though these agents are consistently underutilized because of fear of hemorrhagic complications. Retrospective analyses of large, multicenter trials have more recently showed that stroke risk is somewhat higher with chronic in comparison with paroxysmal AF, but this difference is not sufficiently large to affect anticoagulation recommendations. The studies of anticoagulation use to prevent stroke, as well as most other treatments of AF are based on clinical documentation of the arrhythmia. Typically, this is driven by symptoms such as palpitations, syncope, dyspnea, or chest pain, but sometimes asymptomatic and incidentally discovered. The presence of arrhythmia-related symptoms does not appear to change the stroke risk, so anticoagulation recommendations are unaffected. Although pacemakers have been implanted for >50 …