Silent atrial fibrillation as a stroke risk factor and anticoagulation indication

The term "silent" atrial fibrillation (AF) has recently re-emerged to describe atrial arrhythmias that are detected by implanted cardiac devices but would generally go undetected in the clinical setting. The precise role that silent AF plays in increasing the risk of ischemic stroke is not fully understood. The purpose of this article is to: (1) review the current evidence demonstrating that silent AF is associated with thromboembolic events; (2) describe the temporal proximity of silent AF episodes to thromboembolic events; (3) present data on the incidence of newly detected silent AF in patients without a previous history of AF; and (4) provide an overview of ongoing and new clinical studies on this important topic. The current evidence suggests that the prevalence of silent AF is considerable among patients with implanted devices, and that the presence of silent AF increases the risk of thromboembolism. The AF burden threshold which confers this increased thromboembolism risk is not precisely defined, but might be as brief as several minutes to several hours. The advent of novel oral anticoagulation medications, which offer the promise of improved efficacy along with superior safety profiles, might warrant more aggressive identification of patients who might benefit from these therapies. However, to find high risk patients who have brief episodes of silent AF will likely require new methods of monitoring to permit the detection of this elusive but potentially dangerous arrhythmia.