# Atrial High-Rate Episodes in Elderly Patients: The Anticoagulation Therapy Dilemma

## TL;DR

This paper reviews the challenges of deciding anticoagulation therapy for elderly patients with subclinical atrial fibrillation and suggests ways to better assess their risk.

## Contribution

The paper proposes incorporating new risk factors into the CHA2DS2-VASc score to better stratify stroke risk in patients with atrial high-rate episodes.

## Key findings

- Anticoagulation therapy reduces stroke risk by 32% but increases major bleeding risk by 62% in patients with atrial high-rate episodes.
- Parameters like CKD, obesity, and left atrial volume may improve risk stratification beyond the traditional CHA2DS2-VASc score.
- Future trials are needed to validate the proposed risk stratification method for personalized treatment in subclinical atrial fibrillation.

## Abstract

Atrial fibrillation (AF) has been associated with higher morbidity and mortality rates, especially in older patients. Subclinical atrial fibrillation (SCAF) is defined as the presence of atrial high-rate episodes (AHREs) > 190 bpm for 10 consecutive beats > 6 min and <24 h, as detected by cardiac implanted electronic devices (CIEDs). The selection of eligible patients for anticoagulation therapy among elderly individuals with AHREs detected through CIEDs remains a contentious issue. The meta-analysis of ARTESiA and NOAH-AFNET 6 clinical trials revealed that taking Edoxaban or Apixaban as oral anticoagulation therapy can reduce the risk of stroke by approximately 32% while increasing the risk of major bleeding by approximately 62%. However, it is still unclear which are, among patients with SCAF, those who can take the highest net clinical benefit from anticoagulant therapy. The present review summarizes the current evidence on this intriguing issue and suggests strategies to try to better stratify the risk of stroke and systemic embolism in patients with AHREs. We propose incorporating some parameters including chronic kidney disease (CKD), obesity, enlarged left atrial volume, the efficacy in blood pressure management, and frailty into the traditional CHA2DS2-VASc score. Future trials will be needed to verify the clinical usefulness of the proposed prognostic score mainly in the view of a personalized therapeutic approach in patients with SCAF.