Background: A high incidence of asymptomatic atrial tachycardia and atrial fibrillation (AT/AF) has been recognized in patients with cardiac implantable devices (CIED). The clinical significance of these AT/AF episodes remains unclear. Some “device-detected AT/AF” was previously shown to be triggered by competitive atrial pacing (CAP). Objective: To investigate and characterize a potential association between CAP and AT/AF in the largest series of observations to date. Methods: RATE, a multicenter registry, included 5379 patients with CIEDs followed for approximately 2 years. Electrograms (EGMs) from 1352 patients with AT/AF, CAP, or both were analyzed by experienced adjudicators to assess a causal relationship between AT/AF and CAP onset, duration, and morphology. Results: In 225 patients, 1394 episodes of both AT/AF and CAP were present in the same tracing. CAP and AT/AF were strongly associated (P ≤.02). AT/AF occurred during the course of the study in 71% of patients with CAP. In 62% of the episodes, expert adjudication concluded that CAP triggered AT/AF. The duration and morphology of triggered and spontaneous AT/AF episodes differed. Spontaneous AT/AF episodes were associated with constant EGM morphology, and were either long or extremely short. CAP-triggered AT/AF more often had variable and shorter cycle length EGMs. The incidence of short AT/AF events was higher among triggered episodes (25% vs 12.8%, P <.002). Conclusion: Device-triggered AT/AF due to CAP is likely more common than previously recognized. This AT/AF entity differs from spontaneous AT/AF in duration and morphology. Clinical implications of spontaneous and device-triggered AT/AF may be different.
Bibliographical noteFunding Information:
Disclosures: Dr Michael Orlov has consulting relationship with Biotronik, Boston Scientific, and Abbott (modest) and is a recipient of a research grant from Boston Scientific. Dr Olshansky is a consultant for Amarin and chairman of the DSMB of the REDUCE IT Trial. He is speaker and consultant for Lundbeck. He is consultant for Sanofi Aventis and co-chairman of the GLORIA AF in the United States for Boehringer Ingelheim. Dr Benditt is supported in part by a grant from the Dr Earl E. Bakken family in support of Heart-Brain research. Timothy McIntyre and Melanie Turkel are former employees of St. Jude Medical (now Abbott) who worked on both the RATE registry and the current substudy. Fujian Qu is a current employee of St. Jude Medical (now Abbott) who worked on both the RATE registry and the current substudy. Dr Albert Waldo has a consulting relationship with Biosense Webster (significant), AtriCure, and Milestone Pharmaceuticals (modest) and is a speaker for Pfizer and Bristol-Myers Squibb (modest). The other authors have no conflict of interest.
- Atrial tachyarrhythmias
- Cardiac implantable devices
- Competitive atrial pacing
- Repetitive nonreentrant
- Subclinical atrial fibrillation
- Triggered atrial fibrillation
- Ventriculoatrial synchrony