Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices
Top Cited Papers
Open Access
- 23 April 2015
- journal article
- research article
- Published by Oxford University Press (OUP) in European Heart Journal
- Vol. 36 (26), 1660-1668
- https://doi.org/10.1093/eurheartj/ehv115
Abstract
Atrial tachyarrhythmias (ATs) detected by implanted devices are often atrial fibrillation or flutter (AF) associated with stroke. We hypothesized that introduction and termination of anticoagulation based upon AT monitoring would reduce both stroke and bleeding. We randomized 2718 patients with dual-chamber and biventricular defibrillators to start and stop anticoagulation based on remote rhythm monitoring vs. usual office-based follow-up with anticoagulation determined by standard clinical criteria. The primary analysis compared the composite endpoint of stroke, systemic embolism, and major bleeding with the two strategies. The trial was stopped after 2 years median follow-up based on futility of finding a difference in primary endpoints between groups. A total of 945 patients (34.8%) developed AT, 264 meeting study anticoagulation criteria. Adjudicated atrial electrograms confirmed AF in 91%; median time to initiate anticoagulation was 3 vs. 54 days in the intervention and control groups, respectively (P < 0.001). Primary events (2.4 vs. 2.3 per 100 patient-years) did not differ between groups (HR 1.06; 95% CI 0.75–1.51; P = 0.732). Major bleeding occurred at 1.6 vs. 1.2 per 100 patient-years (HR 1.39; 95% CI 0.89–2.17; P = 0.145). In patients with AT, thromboembolism rates were 1.0 vs. 1.6 per 100 patient-years (relative risk −35.3%; 95% CI −70.8 to 35.3%; P = 0.251). Although AT burden was associated with thromboembolism, there was no temporal relationship between AT and stroke. In patients with implanted defibrillators, the strategy of early initiation and interruption of anticoagulation based on remotely detected AT did not prevent thromboembolism and bleeding. IMPACT ClinicalTrials.gov identifier: NCT00559988 http://clinicaltrials.gov/ct2/show/NCT00559988?term=NCT00559988&rank=1.Keywords
This publication has 27 references indexed in Scilit:
- Effect of Atrial Fibrillation on Atrial Thrombogenesis in Humans: Impact of Rate and RhythmJournal of the American College of Cardiology, 2013
- Subclinical Atrial Fibrillation and the Risk of StrokeNew England Journal of Medicine, 2012
- Detection of atrial high-rate events by continuous Home Monitoring: clinical significance in the heart failure-cardiac resynchronization therapy populationEP Europace, 2011
- The Relationship Between Daily Atrial Tachyarrhythmia Burden From Implantable Device Diagnostics and Stroke RiskCirculation: Arrhythmia and Electrophysiology, 2009
- Multicenter randomized study of anticoagulation guided by remote rhythm monitoring in patients with implantable cardioverter-defibrillator and CRT-D devices: Rationale, design, and clinical characteristics of the initially enrolled cohort: The IMPACT studyAmerican Heart Journal, 2009
- Detection and Quantification of Left Atrial Structural Remodeling With Delayed-Enhancement Magnetic Resonance Imaging in Patients With Atrial FibrillationCirculation, 2009
- Risk of Thromboembolism in Heart FailureCirculation, 2007
- Accuracy of Atrial Tachyarrhythmia Detection in Implantable Devices with Arrhythmia TherapiesPacing and Clinical Electrophysiology, 2004
- Atrial High Rate Episodes Detected by Pacemaker Diagnostics Predict Death and StrokeCirculation, 2003
- Discrete sequential boundaries for clinical trialsBiometrika, 1983