Incremental predictive value of device and echocardiographic parameters for atrial high-rate episodes: a prospective cohort study

Atrial High-Rate Episodes (AHRE) detected by cardiac implantable electronic devices are associated with an increased risk of stroke and atrial fibrillation. This study aimed to evaluate the independent and synergistic predictive value of clinical, echocardiographic, and device-derived parameters for the onset of AHRE ≥ 30 s. In this prospective single-center cohort study, 165 patients undergoing de novo dual-chamber pacemaker implantation were enrolled. Baseline clinical characteristics, echocardiographic indices (including Diastolic Wall Strain [DWS]), biomarkers (NT-proBNP), and device parameters (Atrial Pacing Percentage [AP%] and Paced P-wave Duration [PPD]) were analyzed. The primary endpoint was the first occurrence of AHRE ≥ 30 s. During a median follow-up of 10.5 months, the incidence of AHRE was 21.8% (n = 36). Multivariate Cox regression identified five independent predictors: PPD ≥ 160 ms (HR 4.12), AP% ≥ 50% (HR 3.05), DWS ≤ 0.34 (HR 2.75), Log-transformed NT-proBNP (HR 1.28), and Age (HR 1.24 per 5-year increase). A comprehensive model integrating these factors demonstrated superior discrimination (C-index 0.81) compared to a baseline clinical model (C-index 0.69) and achieved a significant net reclassification index (NRI) of 0.41. Intrinsic electrophysiological markers (prolonged PPD) and mechanical indices of left ventricular stiffness (low DWS) are powerful independent predictors of AHRE. Integrating these parameters significantly improves risk stratification, offering a practical tool for personalized monitoring and management strategies in pacemaker recipients.