1. Atrial fibrillation and subcutaneous monitoring : Will it change our daily practice ? Aymeric MENET Lille January 2016

2. No Disclosure

3. What we knew before the subcutaneous monitoring 0123456789 0,3-0,71à23-45-68-912-1414-1818-20 20-22 Thromboembolism risk/year in AF without treatment = CHADS2VA2SC Aspirin = ↓ 22% Oral Anticoagulants = ↓ 66% Risk of thromboembolism x 3-5 Risk of death x 2, HF, Dyspnea, QoL

4. Risk of stroke according to the FA type Friberg, Eur Heart Journal 2010 Paroxystic vs permanent Hart, JACC 2000 Intermittent vs permanent

5. Risk of stroke according to the FA type Vanassche, Eur Heart Journal 2015 Paroxystic vs permanent But Asymtomatic AF is very frequent Bad detection with Holters (AF > 5min) -44 % si Holter 24h, -50% si Holter 1 semaine -65% si holter de 1 mois Botto GL, J Cadiov Imaging 2009

6. What we learned from the subcutaneous monitoring Burden of AF and stroke Temporal link between AF and stroke

7. 1) AF burden and ThromboEmbolic risk YearStudy Stroke / year rate (n) N (n en AF)Cut-off 2003MOST0,6 vs 2 (10)312 (160)5 min 2005Cappuci et al1,9 (14)743 (743)24h 2009TRENDS1,1 vs 2,4 (40)2486 (1389)>5.5h 2009Botto2,5 (14)568 (568) 5 minutes – >24h 2012 Shunmagan (CRT) 2 (11)560 (224)>3,8 h 2012ASSERT 0,69 vs 1,69 (51) 2580 (261)6mn – 18h 2014 SOS AF project (TRENDS, PANORAMA, Clinicalservice) 0,32 vs 0,67 (95) 10 016 (4306)1 h Few events≈ 40 %AF In PM and IAD

8. 5min1h6h12h24h 6min53min3.6h 17.7h 0.32% 0.43%0.67%0.44% 0.69%1.23%1.18%0% 4.89% SOS AF Project (Trends, Panorama, clinical service), n= 10 016 (95) ASSERT, n= 2580 (51) Healey, NEJM 2014 AF burden

9. Boriani, Eur Heart Journal 2014Botto, J Cardiovasc Electrophy 2009 2 AF burden

10. Risk of stroke according to the FA type Vanassche, Eur Heart Journal 2015 Paroxystic vs permanent CHADSVASC 0-1 + FA parox = 0.8% stroke/year

11. Boriani, Eur Heart Journal 2014Botto, J Cardiovasc Electrophy 2009 DONC: 1h si CHADSVASC >0 5minutes si CHADS2>1 Conclusion In silent AF and patients with pace maker of defibrillator CHADS2VAS2C 0 => no anticoagulants CHADS2VAS2C ≥ 2 => anticoagulant if AF > 5-6 minutes CHADS2VAS2C 1 => anticoagulant only if AF> 1h (18h), paroxystic ?

12. Can we stop the anticoagulation ? Is AF a cause of stroke, or an associated factor? 2) Temportal link between AF and TE

13. IMPACT study (n=2718) Endpoint: TE + bleeding Randomized: Intermittent AOC vs continuous AOC Population: Implantable defibrillators Martin, European Heart Journal 2015

14. 6 month before TE

15. Atrial fibrillation may be a marker of more generalized « atriopathy » 1/3 1/3 1/3 prior >30 days prior <30 days after

16. Rôle of Atriopathy ? Akoum, J Cadiovascular Electrophysiol. 2013

17. Conclusion: How subcutaneus monitoring does change our daily practice 1. AF burden and silent AF with PM or IAD : early detection CHADS2VAS2C 0 => no d’anticoagulants CHADS2VAS2C ≥ 2 => anticoagulant if AF > 5-6 minutes CHADS2VAS2C 1 => anticoagulant only if AF > 1h, 18h, paroxystic ? 2. Few temporal link between AF and stroke

18. Expecting : REACT.COM study Randomized: Intermittent AOC vs continuous AOC Population: AF and CHADS 1/2 Randomized: Intermittent AOC vs continuous AOC ?

19. YearStudy: n TE (n in AFAF prior > 30 days AF prior < 30 days After only 2009TRENDS: 40 (26)9 (35%)11(42%)6 (23%) 2012ASSERT: 51 (26)18(69%)8 (31%) 1/3 1/3 1/3 prior >30 days prior <30 days after