The Clinical Outcomes and Therapeutic Effects in Patients With Cardiac Implantable Electronic Device-detected Subclinical and Clinical Atrial Fibrillation. (AHRE)

Atrial high-rate episodes (AHREs) detected by cardiac implantable electronic devices (CIEDs) are increasingly recognized as an early stage of atrial fibrillation (AF) and are associated with an elevated risk of AF progression, stroke, heart failure, and mortality. However, the optimal management of patients with device-detected AHREs remains uncertain, particularly for individuals with episodes lasting between 6 minutes and 24 hours. Current management strategies generally focus on risk factor modification and clinical surveillance, while evidence supporting early rhythm-control intervention in this population is limited.

Observational studies have demonstrated that progression from shorter-duration AHREs to sustained AHREs (≥24 hours) is associated with substantially worse clinical outcomes and may represent an important stage in the evolution of atrial cardiomyopathy. Preventing progression of AHREs may therefore provide an opportunity to alter the natural history of AF and reduce future cardiovascular complications.

This prospective, randomized, open-label, controlled trial is designed to evaluate whether an early rhythm-control strategy can reduce progression of device-detected AHREs compared with usual care. Eligible participants are adults with CIED-detected AHREs lasting between 6 minutes and 24 hours and without a prior diagnosis of clinical atrial fibrillation. Participants will be randomly assigned in a 1:1 ratio to either a rhythm-control strategy or usual care.

The rhythm-control strategy may include antiarrhythmic drug therapy, catheter ablation, or other guideline-directed rhythm-control interventions at the discretion of the treating physician. Both groups will receive comprehensive management of cardiovascular risk factors according to contemporary clinical practice guidelines.

The primary endpoint is a composite of progression to sustained AHREs (≥24 hours) or development of clinically documented atrial fibrillation during follow-up. Secondary endpoints include changes in AHRE burden, ischemic stroke, systemic embolism, heart failure hospitalization, cardiovascular death, all-cause mortality, and treatment-related adverse events.

Participants will undergo regular device interrogation and clinical follow-up throughout the study period. The study aims to determine whether early rhythm-control intervention can delay AF progression and improve long-term cardiovascular outcomes in patients with device-detected AHREs.