Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10-30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.

Arrhythmias Unit of Cardiology Department Hospital Prof Dr Fernando Fonseca Amadora Sintra Portugal

Atrial Fibrillation NETwork Muenster Germany

Cardiac Electrophysiology Section European Georges Pompidou Hospital Paris France

Cardiology Clinic St Anna University Hospital Medical University Sofia Sofia Bulgaria

Cardiovascular Clinical Institute Hospital Clinic Universitat de Barcelona Catalonia Spain

Colentina University Hospital Medicine University Carol Davila Bucharest Romania

Department of Cardiac Vascular and Thoracic Sciences Azienda Ospedaliera Padua Italy

Department of Cardiology Heart Center Amsterdam University Medical Center University of Amsterdam Amsterdam the Netherlands

Department of Cardiology Odense University Hospital Odense Denmark

Department of Clinical Research University of Southern Denmark Odense Denmark

Department of Interventional Cardiology and Arrhythmias Medical University of Lodz Lodz Poland

Department of Medical Science Uppsala University Uppsala Sweden

Eastbourne District General Hospital Eastbourne UK

Heart and Vascular Center Semmelweis University Budapest Budapest Hungary

Heart Sector Hygeia Group Hospitals Athens Greece

Herzzentrum Dresden GmbH Universitätsklinikum Dresden Germany

Institute for Clinical and Experimental Medicine Prague Czech Republic

Institute of Cardiovascular Sciences University of Birmingham UHB and Sandwell and West Birmingham Hospitals NHS Trusts IBR 126a Wolfson Drive Birmingham B15 2TT UK

St Vincenz Hospital Paderborn Cardiology and Intensive Care Medicine Paderborn Germany

Universitair Ziekenhuis Antwerpen Edegem Belgium

University Hospital of Internal Medicine 3 Medical University Innsbruck Innsbruck Austria

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The influence of atrial high-rate episodes on stroke and cardiovascular death: an update