On 2014 Mar 17, Gaetano Santulli commented:

Healey et al. report that subclinical atrial fibrillation (AF) is associated with an increased risk of ischemic stroke or systemic embolism (1). This finding is really intriguing, but the interpretation is problematic in that the Authors did not mention in their analysis some widely recognized independent risk factors for ischemic stroke, such as smoking status and left atrial size (2, 3). These factors clearly partake in the pathophysiology of AF-associated stroke, which is indeed mainly due to embolism of thrombus formed during stasis of blood in the left atrial appendage (2). Furthermore, there is a well-known connection between atrial dimensions and new-onset AF (4). Thus, subclinical episodes of AF could be simply a marker of stroke risk, indicating another underlying disease (2). In this trial (1), the risk of stroke was improperly assessed using the CHADS2 score (5), which was instead specifically designed just for patients with overt AF. To better understand the prognostic clinical implications of asymptomatic AF, it would be of interest to validate the significancy of provided results after correction for the omitted risk factors.

Disclosures: None.

References 1. Healey JS, Connolly SJ, Gold MR, et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012;366:120-9. 2. Sacco RL, Benjamin EJ, Broderick JP, et al. American Heart Association Prevention Conference. IV. Prevention and Rehabilitation of Stroke. Risk factors. Stroke 1997;28:1507-17. 3. Benjamin EJ, D’Agostino RB, Belanger AJ, Wolf PA, Levy D. Left atrial size and the risk of stroke and death. The Framingham Heart Study. Circulation 1995;92:835-41. 4. Tsang TS, Barnes ME, Bailey KR, et al. Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women. Mayo Clin Proc 2001;76:467-75. 5. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001;285:2864-70.

Gaetano Santulli, MD, PhD Columbia University Medical Center New York, NY - USA

On 2014 Mar 17, Gaetano Santulli commented:

Healey et al. report that subclinical atrial fibrillation (AF) is associated with an increased risk of ischemic stroke or systemic embolism (1). This finding is really intriguing, but the interpretation is problematic in that the Authors did not mention in their analysis some widely recognized independent risk factors for ischemic stroke, such as smoking status and left atrial size (2, 3). These factors clearly partake in the pathophysiology of AF-associated stroke, which is indeed mainly due to embolism of thrombus formed during stasis of blood in the left atrial appendage (2). Furthermore, there is a well-known connection between atrial dimensions and new-onset AF (4). Thus, subclinical episodes of AF could be simply a marker of stroke risk, indicating another underlying disease (2). In this trial (1), the risk of stroke was improperly assessed using the CHADS2 score (5), which was instead specifically designed just for patients with overt AF. To better understand the prognostic clinical implications of asymptomatic AF, it would be of interest to validate the significancy of provided results after correction for the omitted risk factors.

Disclosures: None.

References 1. Healey JS, Connolly SJ, Gold MR, et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012;366:120-9. 2. Sacco RL, Benjamin EJ, Broderick JP, et al. American Heart Association Prevention Conference. IV. Prevention and Rehabilitation of Stroke. Risk factors. Stroke 1997;28:1507-17. 3. Benjamin EJ, D’Agostino RB, Belanger AJ, Wolf PA, Levy D. Left atrial size and the risk of stroke and death. The Framingham Heart Study. Circulation 1995;92:835-41. 4. Tsang TS, Barnes ME, Bailey KR, et al. Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women. Mayo Clin Proc 2001;76:467-75. 5. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001;285:2864-70.

Gaetano Santulli, MD, PhD Columbia University Medical Center New York, NY - USA