Cardiac implanted electronic devices (CIEDs), including pacemakers and implantable defibrillators that perform atrial sensing typically using an atrial electrode, frequently detect subclinical atrial high-rate episodes (AHREs). When the intracardiac electrograms are carefully examined, the majority of AHREs are atrial fibrillation (AF) or other atrial tachyarrhythmias, which have been shown to be associated with both an increased risk of stroke, and subsequent development of clinical AF. However, the absolute risk of stroke among patients with AHREs is less than might be expected for clinically diagnosed paroxysmal AF. In addition, a close temporal relationship between AHREs and stroke is seen in only 15% of strokes in patients with a CIED: the majority have either no AHREs before the stroke, or AHREs very distant from incident stroke, suggesting that AHREs might be more of a risk marker than a risk factor for stroke. Management of AHREs should not be the same as for clinical AF, and a degree of uncertainty underpins the rationale for much-needed, ongoing, randomized trials of oral anticoagulation in patients with CIED-detected AHREs. We propose a management algorithm that takes into account both the stroke risk and the AHRE burden, but highlights the current uncertainty and evidence gaps for this condition.

心脏植入电子设备 (CIED)，包括通常使用心房电极执行心房感应的起搏器和植入式除颤器，经常检测亚临床心房高频发作 (AHRE)。当仔细检查心内电图时，大多数 AHRE 是心房颤动 (AF) 或其他心房快速性心律失常，这已被证明与中风风险的增加以及随后临床 AF 的发展有关。然而，AHRE 患者中风的绝对风险低于临床诊断为阵发性 AF 的预期风险。此外，仅 15% 的 CIED 患者卒中发现 AHRE 与卒中之间存在密切的时间关系：大多数人在卒中前没有 AHRE，或者 AHRE 与卒中事件相距甚远，表明 AHRE 可能更像是一种风险标志物，而不是中风的风险因素。AHREs 的管理不应与临床 AF 相同，并且一定程度的不确定性支撑了对 CIED 检测到的 AHREs 患者进行急需、正在进行的口服抗凝剂随机试验的基本原理。我们提出了一种管理算法，该算法同时考虑了中风风险和 AHRE 负担，但强调了目前这种情况的不确定性和证据差距。