Is competitive atrial pacing a possible trigger for atrial fibrillation? Observations from the RATE registry

Michael V. Orlov; Brian Olshansky; David G. Benditt; Gregory Kotler; Timothy McIntyre; Qu Fujian Qu; Melanie Turkel; Maxim Gorev; Hermine Poghosyan; Albert L. Waldo

doi:10.1016/j.hrthm.2020.07.028

Is competitive atrial pacing a possible trigger for atrial fibrillation? Observations from the RATE registry

Michael V. Orlov, Brian Olshansky, David G. Benditt, Gregory Kotler, Timothy McIntyre, Qu Fujian Qu, Melanie Turkel, Maxim Gorev, Hermine Poghosyan, Albert L. Waldo

Medicine - Cardiology Division

Research output: Contribution to journal › Article › peer-review

Abstract

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.

Original language	English (US)
Pages (from-to)	3-9
Number of pages	7
Journal	Heart Rhythm
Volume	18
Issue number	1
DOIs	https://doi.org/10.1016/j.hrthm.2020.07.028
State	Published - Jan 2021

Bibliographical note

Funding 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.

Keywords

Atrial tachyarrhythmias
Cardiac implantable devices
Competitive atrial pacing
Electrogram
Repetitive nonreentrant
Subclinical atrial fibrillation
Triggered atrial fibrillation
Ventriculoatrial synchrony

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Is competitive atrial pacing a possible trigger for atrial fibrillation? Observations from the RATE registry. / Orlov, Michael V.; Olshansky, Brian; Benditt, David G.; Kotler, Gregory; McIntyre, Timothy; Fujian Qu, Qu; Turkel, Melanie; Gorev, Maxim; Poghosyan, Hermine; Waldo, Albert L.

In: Heart Rhythm, Vol. 18, No. 1, 01.2021, p. 3-9.

Research output: Contribution to journal › Article › peer-review

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title = "Is competitive atrial pacing a possible trigger for atrial fibrillation? Observations from the RATE registry",

abstract = "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.",

keywords = "Atrial tachyarrhythmias, Cardiac implantable devices, Competitive atrial pacing, Electrogram, Repetitive nonreentrant, Subclinical atrial fibrillation, Triggered atrial fibrillation, Ventriculoatrial synchrony",

author = "Orlov, {Michael V.} and Brian Olshansky and Benditt, {David G.} and Gregory Kotler and Timothy McIntyre and {Fujian Qu}, Qu and Melanie Turkel and Maxim Gorev and Hermine Poghosyan and Waldo, {Albert L.}",

note = "Funding 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.",

year = "2021",

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doi = "10.1016/j.hrthm.2020.07.028",

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T1 - Is competitive atrial pacing a possible trigger for atrial fibrillation? Observations from the RATE registry

AU - Orlov, Michael V.

AU - Olshansky, Brian

AU - Benditt, David G.

AU - Kotler, Gregory

AU - McIntyre, Timothy

AU - Fujian Qu, Qu

AU - Turkel, Melanie

AU - Gorev, Maxim

AU - Poghosyan, Hermine

AU - Waldo, Albert L.

N1 - Funding 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.

PY - 2021/1

Y1 - 2021/1

N2 - 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.

AB - 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.

KW - Atrial tachyarrhythmias

KW - Cardiac implantable devices

KW - Competitive atrial pacing

KW - Electrogram

KW - Repetitive nonreentrant

KW - Subclinical atrial fibrillation

KW - Triggered atrial fibrillation

KW - Ventriculoatrial synchrony

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