Antithrombotic therapy in patients with atrial high-rate episodes (AHREs): Current evidence and open questions

With the increasing use of cardiac electronic implantable devices in recent years, the identification of asymptomatic atrial arrhythmias, including atrial high-rate episodes (AHREs) and device-detected subclinical atrial fibrillation (SCAF), has become common in clinical practice. AHREs have potentially important clinical implications because they are considered precursors of atrial fibrillation (AF). Although to a lesser extent than clinical AF, both AHREs and device-detected SCAF are associated with thromboembolic events, however routine use of anticoagulants in these conditions is not recommended. In addition, patients with AHREs are at increased risk of cardiovascular events, including myocardial infarction, heart failure, and cardiovascular hospitalization. The relationship between stroke and AHREs and the potential benefit of anticoagulant therapy in this setting is the subject of ongoing debate. In this review, we aimed to appraise the available evidence and current gaps in the risk stratification and management of patients with AHREs/device-detected SCAF. •Atrial high-rate episodes (AHREs) and subclinical atrial fibrillation (SCAF) are common in contemporary clinical practice.•AHREs and SCAF have important clinical implications as they are considered precursors of atrial fibrillation and are associated with increased risk of thromboembolic events.•Current guidelines do not recommend routine use of anticoagulation therapy in patients with AHREs/SCAF.•The relationship between stroke and AHREs and the potential benefit of long-term anticoagulation therapy in this setting remains controversial.