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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EAtrial fibrillation (AF) is the most common sustained cardiac rhythm disorder, affecting 3 million people in the United States and 35 million worldwide. Patients with AF have a substantial risk for mortality and morbidity from ischemic stroke, which occurs at 5 times the rate as in the general population. The risk of stroke in people with AF is about 5% per year and AF-related strokes tend to be more severe than strokes in patients without AF [Magnani JW et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011]. This article discusses the diagnosis and treatment of silent AF.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAtrial fibrillation (AF) is the most common sustained cardiac rhythm disorder, affecting 3 million people in the United States and 35 million worldwide. Patients with AF have a substantial risk for mortality and morbidity from ischemic stroke, which occurs at 5 times the rate as in the general population. The risk of stroke in people with AF is about 5% per year and AF-related strokes tend to be more severe than strokes in patients without AF [Magnani JW et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESilent Atrial Fibrillation\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EJean-Claude Deharo, H\u00f4pital Sainte-Marguerite, Marseilles, France, discussed the diagnosis and treatment of silent AF. According to the European Heart Rhythm Association, classification of AF-related symptoms, silent (asymptomatic) AF is classified as Class I AF. Visual inspection of the electrocardiogram (ECG) is the gold standard for diagnosis of AF. Silent AF usually is diagnosed at routine physical examination, by office ECG, at preoperative assessment, in population surveys, after stroke or diagnosis of heart failure, or in patients with implanted devices.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThe Canadian Registry of Atrial Fibrillation [CARAF] study found that of 674 patients diagnosed with AF, 142 were asymptomatic. Asymptomatic AF was more likely to occur at an older age, in men, in patients without hypertension, and in those with a lower heart rate [Kerr C et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 1996]. Savelieva and Camm [\u003Cem\u003EJ Interv Card Electrophysiol\u003C\/em\u003E 2000] reported that patients with silent AF have significantly lower quality of life as measured by Global Life Satisfaction score (7.3\u00b11.6) compared with controls (8.0\u00b11.2; p\u0026lt;0.003) but not as low as patients with symptomatic AF (5.9\u00b11.9). Patients with silent AF also had similar mortality rates to those with symptomatic AF [Savelieva I et al. \u003Cem\u003EHeart\u003C\/em\u003E 2001].\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EIn a subanalysis of 312 patients from the Mode Selection Trial [MOST], the presence of any atrial high-rate events (AHRE) after 1 year of pace monitoring was an independent predictor of a 2.79 times increased risk of death or nonfatal stroke (95% CI, 1.51 to 5.15; p=0.0011) [Glotzer TV et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2003]. In the TRENDS study, 2486 patients with \u22651 risk factor for stroke were monitored for atrial tachycardia (AT)\/AF burden (longest total AT\/AF duration on any given day during the prior 30-day period) [Glotzer TV et al. \u003Cem\u003ECirc Arrhythm Electrophysiol\u003C\/em\u003E 2009]. Compared with patients with a zero AT\/AF burden, patients with a low AT\/AF burden (\u0026lt;5.5 hours) had an HR for risk of thromboembolic events (TE) of 0.98 (95% CI, 0.34 to 2.82; p=0.97) while the HR was 2.20 (95% CI, 0.96 to 5.05; p=0.06) for those with a high burden (\u22655.5 hours).\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EShanmugam et al. [\u003Cem\u003EEuropace\u003C\/em\u003E 2012] found that in 560 patients with a cardiac resynchronization device, those with a high AHRE (\u0026gt;3.8 hours over a day) had a significantly increased risk of TE (HR, 9.4; 95% CI, 1.8 to 47.0; p=0.006), TE plus cardiovascular (CV) death (HR, 4.0; 95% CI, 1.5 to 10.1; p=0.004), and TE plus AF plus heart failure (HF) plus CV death (HR, 3.8; 95% CI, 2.3 to 6.3; p\u0026lt;0.0001) compared with patients with zero AHRE. High AHRE patients also had an increased risk of TE plus AF plus HF plus CV death versus patients with low AHRE (HR, 3.69; 95% CI, 1.9 to 7.9; p\u0026lt;0.0001) but not for TE alone or TE plus CV death (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/12769\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/12769\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12769\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003EHigh Versus Low AHRE: Clinical Outcomes.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EHealey et al. [\u003Cem\u003EN Engl J Med\u003C\/em\u003E 2012] evaluated 2580 patients \u226565 years old with a pacemaker or implanted cardioverter defibrillator with no hypertension or history of AF. After 3 months, patients who had subclinical atrial tachyarrhythmias had a significantly increased risk of ischemic stroke or systemic embolism versus those who did not (HR, 2.49; 95% CI, 1.28 to 4.85; p=0.007), ischemic stroke (HR, 2.52; 95% CI, 1.25 to 5.08; p=0.01), and clinical AF or flutter on surface ECG (HR, 5.56; 95% CI, 3.78 to 8.17; p\u0026lt;0.001).\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EAccording to Prof. Deharo, patients with silent AF should have sinus rhythm restoration. Cardioversion should be followed with antiarrhythmic drug (AAD) therapy only if it will benefit the patient\u0027s quality of life. As with symptomatic AF patients, those with silent AF should also be treated with ventricular rate control and anticoagulation but not with AF ablation.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ELeft Atrial Appendage Occluder for Stroke Prevention\u003C\/h2\u003E\n         \u003Cp id=\u0022p-11\u0022\u003ECurrent treatments for AF include anticoagulation for stroke prevention and rate control with AADs, ablation, and cardioversion. More than 90% of thrombi in patients with AF occur in the left atrial appendage (LAA) [Hur J et al. \u003Cem\u003EStroke\u003C\/em\u003E 2011]. Anticoagulation for the prevention of stroke is recommended in patients with a CHADS\u003Csub\u003E2\u003C\/sub\u003E score \u22652 and as an alternative to aspirin in those with a CHADS\u003Csub\u003E2\u003C\/sub\u003E score of 1. The 2010 ESC Guidelines for the management of AF [Camm AJ et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2010] recommend oral anticoagulation (OAC) for patients with 1 major risk factor or \u22652 clinically relevant nonmajor factors (CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score \u22652) and as an alternative to aspirin in patients with 1 clinically relevant nonmajor risk factor (CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score=1).\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ESamih Lawand, MD, King Fahad Medical City, Riyadh, Saudi Arabia, reported study results comparing the use of an LAA occluder with warfarin for stroke prevention in patients with AF. Fewer than 25% of all patients with AF and only 70% of patients considered ideal candidates for warfarin are treated with the OAC. Moreover, only 50% to 68% of patients on warfarin are in the therapeutic range [Whitlock RP et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2009]. Warfarin is underutilized for several reasons, including bleeding risk, difficulty with international normalized ratio monitoring, noncompliance, patient preference, and pharmacokinetic interference with other drugs and food.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/8\/20.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznacd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nznacd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}