Device-Detected Atrial High-Rate Episodes and Risk of Ischaemic Stroke and Progression to Atrial Fibrillation: A Systematic Review and Meta-Analysis

BackgroundThere is a well-established association between atrial fibrillation and an increased risk of ischaemic stroke, new evidence however suggests that atrial tachycardia (AT) may also contribute to this risk. Through cardiac remodelling pathways and physiological changes, a multi-faceted risk of stroke exists. Our review suggests there is an increased risk of ischaemic stroke in the presence of AT and additionally a greater risk of developing overt AF after these events. There are however many inconsistencies within the studies including ambiguity surrounding AHRE definitions, control for anticoagulation and concurrent AF episodes that are not often reported. Further research is warranted to better define atrial high-rate episodes to further characterise this relationship. Whilst there is clinical direction for anticoagulation in patients with AF, there are no standardised indications for intermediate durations of AHREs and oral anticoagulation is largely determined on an individual basis. Given this gap within clinical practice, we performed a review of the literature to explore if a relationship between episodes of AT and ischemic stroke exists, excluding those with a history of prior AF.AimsTo systematically review and meta-analyse the association between device-detected atrial tachycardia/AHREs and (i) risk of ischaemic stroke and (ii) progression to clinical AF, excluding patients with a prior history of AF.Summary of reviewA systematic review was conducted according to PRISMA guidelines (PROSPERO CRD42022337209). MEDLINE, EMBASE, and Cochrane databases were searched to 10 March 2025. Nine studies (n = 5,099 patients) met inclusion criteria. Overall, 33.7% experienced at least one AHRE, and 2.5% developed a thromboembolic event during follow-up. Meta-analysis of six studies demonstrated a 2.6-fold increased risk of ischaemic stroke in patients with AHREs (pooled HR 2.59, 95% CI 1.54-3.64; I² = 0%). A second meta-analysis demonstrated a 4.5-fold increased risk of progression to AF (pooled effect size 4.51, 95% CI 1.50-7.51; I² = 73.1%). Amongst the reviewed studies, definitions of AHRE duration and rate varied substantially.ConclusionsDevice-detected AHREs are associated with a significantly increased risk of ischaemic stroke and progression to clinical AF in patients without prior AF. While the magnitude of stroke risk is lower than that reported for overt AF, AHREs represent a clinically meaningful risk marker. Standardised definitions and burden thresholds are required to guide anticoagulation strategies and optimise stroke prevention.