Clinical relevance and management of atrial high-rate episodes: a narrative review

Atrial high-rate episodes (AHREs) are atrial tachyarrhythmias detected by cardiac implantable electronic devices when the atrial rate exceeds the device’s programmed detection threshold. The frequency and duration of these episodes vary, with those lasting more than 5 min generally considered clinically significant. The occurrence of AHREs has been associated, in multiple clinical trials, with an increased risk of progression to overt atrial fibrillation (AF) and a higher incidence of thromboembolic events, particularly ischemic stroke. Several studies have demonstrated that the strength of these associations is directly proportional to AHREs duration and is further influenced by comorbidities such as advanced age, hypertension, and a history of heart failure. Despite the elevated embolic risk, clinical uncertainty persists regarding the optimal timing and indication for initiating long-term oral anticoagulation in patients with AHREs. Consequently, this narrative review aims to outline a contemporary clinical approach and propose a treatment algorithm for AHREs, grounded in the current body of evidence.