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      <span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia><span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Abstract</span></p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Background&#58;</span> One quarter of strokes are of unknown cause&#44; and subclinical atrial fibrillation may be a common etiologic factor&#46; Pacemakers can detect subclinical episodes of rapid atrial rate&#44; which correlate with electrocardiographically documented atrial fibrillation&#46; We evaluated whether subclinical episodes of rapid atrial rate detected by implanted devices were associated with an increased risk of ischemic stroke in patients who did not have other evidence of atrial fibrillation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Methods&#58;</span> We enrolled 2580 patients&#44; 65 years of age or older&#44; with hypertension and no history of atrial fibrillation&#44; in whom a pacemaker or defibrillator had recently been implanted&#46; We monitored the patients for 3 months to detect subclinical atrial tachyarrhythmias &#40;episodes of atrial rate &#62;190 beats per minute for more than 6<span class="elsevierStyleHsp" style=""></span>minutes&#41; and followed them for a mean of 2&#46;5 years for the primary outcome of ischemic stroke or systemic embolism&#46; Patients with pacemakers were randomly assigned to receive or not to receive continuous atrial overdrive pacing&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Results&#58;</span> By 3 months&#44; subclinical atrial tachyarrhythmias detected by implanted devices had occurred in 261 patients &#40;10&#46;1&#37;&#41;&#46; Subclinical atrial tachyarrhythmias were associated with an increased risk of clinical atrial fibrillation &#40;hazard ratio&#44; 5&#46;56&#59; 95&#37; confidence interval &#91;CI&#93;&#44; 3&#46;78 to 8&#46;17&#59; P&#60;0&#46;001&#41; and of ischemic stroke or systemic embolism &#40;hazard ratio&#44; 2&#46;49&#59; 95&#37; CI&#44; 1&#46;28 to 4&#46;85&#59; P&#61;0&#46;007&#41;&#46; Of 51 patients who had a primary outcome event&#44; 11 had had subclinical atrial tachyarrhythmias detected by 3 months&#44; and none had had clinical atrial fibrillation by 3 months&#46; The population attributable risk of stroke or systemic embolism associated with subclinical atrial tachyarrhythmias was 13&#37;&#46; Subclinical atrial tachyarrhythmias remained predictive of the primary outcome after adjustment for predictors of stroke &#40;hazard ratio&#44; 2&#46;50&#59; 95&#37; CI&#44; 1&#46;28 to 4&#46;89&#59; P&#61;0&#46;008&#41;&#46; Continuous atrial overdrive pacing did not prevent atrial fibrillation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusions&#58;</span> Subclinical atrial tachyarrhythmias&#44; without clinical atrial fibrillation&#44; occurred frequently in patients with pacemakers and were associated with a significantly increased risk of ischemic stroke or systemic embolism&#46; &#40;Funded by St&#46; Jude Medical&#59; ASSERT ClinicalTrials&#46;gov number&#44; NCT00256152&#41;&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">&lt;rohs1&gt;\n
       Coment&#225;rio\n
      &lt;/rohs1&gt;</span><p id="par0040" class="elsevierStylePara elsevierViewall">&#201; sabido que o n&#250;mero de epis&#243;dios assintom&#225;ticos de fibrilha&#231;&#227;o auricular &#233; superior ao n&#250;mero de epis&#243;dios sintom&#225;ticos&#46; Por outro lado e embora 10 a 15&#37; dos acidentes vasculares cerebrais seja atribu&#237;vel a fibrilha&#231;&#227;o auricular documentada&#44; em 25&#37; dos acidentes isqu&#233;micos n&#227;o se consegue identificar um fator etiol&#243;gico &#40;AVC criptog&#233;nico&#41;&#46; Admite-se que alguns destes AVC sejam devidos a FA subcl&#237;nica&#44; embora se desconhe&#231;a a preval&#234;ncia e o progn&#243;stico desta entidade&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">O estudo ASSERT &#40;&#171;Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial&#187;&#41; incluiu 2500 doentes hipertensos com mais que 65 anos submetidos a implanta&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span>&#47;CDI de dupla c&#226;mara&#46; Doentes com hist&#243;ria de FA&#47;<span class="elsevierStyleItalic">flutter</span> documentados ou doentes sob hipocoagula&#231;&#227;o oral foram exclu&#237;dos do estudo&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">O estudo tinha 2 objetivos prim&#225;rios&#58; &#40;1&#41; &#8211; a avalia&#231;&#227;o da associa&#231;&#227;o entre epis&#243;dios assintom&#225;ticos de fibrilha&#231;&#227;o auricular e o risco de AVC isqu&#233;mico e &#40;2&#41; &#8211; a avalia&#231;&#227;o da efic&#225;cia de <span class="elsevierStyleItalic">pacing</span> auricular mais r&#225;pido do que o ritmo intr&#237;nseco do doente <span class="elsevierStyleItalic">&#40;overdrive pacing&#41;</span> na preven&#231;&#227;o de epis&#243;dios cl&#237;nicos de fibrilha&#231;&#227;o auricular&#46; No seguimento&#44; a interroga&#231;&#227;o dos aparelhos documentava se tinham ou n&#227;o existido epis&#243;dios de arritmias auriculares &#40;definidos para o ensaio como a ocorr&#234;ncia de frequ&#234;ncias auriculares superiores a 190&#47;min durante pelo menos 6 minutos&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Os resultados deste estudo mostram que o n&#250;mero de epis&#243;dios nesta popula&#231;&#227;o &#233; elevado &#8211; aos 3 meses de seguimento&#44; em 10&#44;1&#37; dos doentes tinham existido epis&#243;dios assintom&#225;ticos de fibrilha&#231;&#227;o auricular &#40;com uma mediana de 2 epis&#243;dios&#47;doente&#41;&#46; Apenas em 0&#44;03&#37; &#40;7 doentes&#41; ocorreram epis&#243;dios sintom&#225;ticos&#46; Num seguimento m&#233;dio de 2&#44;5 anos ocorreram arritmias auriculares em mais 24&#44;5&#37; dos doentes&#46; Houve epis&#243;dios de fibrilha&#231;&#227;o auricular sintom&#225;tica em mais doentes que tinham tido arritmias assintom&#225;ticas nos primeiros 3 meses &#40;15&#44;7 <span class="elsevierStyleItalic">versus</span> 3&#44;1&#37;&#44; HR 5&#44;56&#44; p &#60; 0&#44;01&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Durante o seguimento&#44; 4&#44;2&#37; dos doentes com arritmias auriculares assintom&#225;ticas nos primeiros 3 meses tiveram AVC isqu&#233;mico &#40;1&#44;69&#37;&#47;ano&#41;&#44; n&#250;mero significativamente superior do que nos doentes sem arritmias subcl&#237;nicas &#40;1&#44;7&#37;&#44; 0&#44;69&#37;&#47;ano&#41;&#46; O risco &#40;HR 2&#44;5&#44; p &#60; 0&#44;01&#41; manteve-se semelhante ap&#243;s ajuste para os fatores de risco basal de ambos os grupos&#46; Do total de doentes com AVC isqu&#233;mico&#44; 21&#37; tinha tido epis&#243;dios assintom&#225;ticos de arritmias auriculares e nenhum tido FA cl&#237;nica&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Estes resultados s&#227;o importantes&#44; porque estabelecem uma associa&#231;&#227;o clara entre epis&#243;dios assintom&#225;ticos de fibrilha&#231;&#227;o auricular e o acidente vascular cerebral&#46; Esta associa&#231;&#227;o&#44; embora do ponto de vista fisiopatol&#243;gico parecesse ser evidente&#44; n&#227;o tinha sido demonstrada at&#233; hoje num grande ensaio cl&#237;nico&#46; Estas arritmias surgem muito esporadicamente &#40;mediana de tempo at&#233; primeiro epis&#243;dio de 35 dias&#41; &#8211; o que faz com que os m&#233;todos de diagn&#243;stico convencional &#40;Holter de 24<span class="elsevierStyleHsp" style=""></span>h ou mesmo Holters de 5-7 dias&#41; tenham muito pouco valor no seu diagn&#243;stico&#46; Por outro lado&#44; demonstra ainda que mesmo epis&#243;dios de curta dura&#231;&#227;o de fibrilha&#231;&#227;o auricular t&#234;m implica&#231;&#227;o no que diz respeito a fen&#243;menos emb&#243;licos&#46; Parece haver uma tend&#234;ncia para que epis&#243;dios de mais longa dura&#231;&#227;o tenham um risco superior de embolia&#44; embora os autores reconhe&#231;am que n&#227;o h&#225; poder estat&#237;stico no ensaio para o demonstrar&#46; Por outro lado&#44; &#233; tamb&#233;m poss&#237;vel especular que&#44; se a dura&#231;&#227;o escolhida para a defini&#231;&#227;o dos epis&#243;dios de fibrilha&#231;&#227;o fosse mais baixa &#40;inferior a 6 minutos&#41;&#44; n&#227;o s&#243; o n&#250;mero de epis&#243;dios seria maior mas&#44; provavelmente o risco emb&#243;lico se manteria elevado&#46; Outro aspeto interessante &#233; que o <span class="elsevierStyleItalic">score</span> de CHADS2 modula o risco emb&#243;lico tamb&#233;m nesta situa&#231;&#227;o &#8211; quanto maior o n&#250;mero de fatores de risco&#44; maior o risco emb&#243;lico&#44; demonstrando&#44; uma vez mais&#44; o enorme poder preditivo deste &#237;ndice de aplica&#231;&#227;o simples&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">N&#227;o h&#225; qualquer refer&#234;ncia no estudo a uma associa&#231;&#227;o temporal entre os epis&#243;dios detetados e os fen&#243;menos emb&#243;licos observados&#46; Fica assim por esclarecer se os epis&#243;dios assintom&#225;ticos detetados precedem por horas ou dias os fen&#243;menos emb&#243;licos&#44; ou se h&#225; sequer alguma rela&#231;&#227;o temporal&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o ao segundo objetivo do estudo &#8211; n&#227;o houve qualquer diferen&#231;a em rela&#231;&#227;o ao n&#250;mero de epis&#243;dios de arritmias auriculares nos doentes com o algoritmo de <span class="elsevierStyleItalic">overdrive pacing</span> ativado&#46; Este resultado n&#227;o &#233; muito diferente do que tem sido encontrado noutros ensaios cl&#237;nicos destes algoritmos&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">O presente estudo traz&#44; assim&#44; novas informa&#231;&#245;es importantes sobre a associa&#231;&#227;o entre fibrilha&#231;&#227;o auricular &#40;mesmo que assintom&#225;tica e mesmo que de curta dura&#231;&#227;o&#41; e o acidente vascular emb&#243;lico&#46; &#201; poss&#237;vel que este conhecimento venha a trazer altera&#231;&#245;es na interven&#231;&#227;o diagn&#243;stica e terap&#234;utica destes doentes&#46; Com o desenvolvimento da tecnologia e com registadores de eventos implant&#225;veis cada vez menores &#40;h&#225; j&#225; prot&#243;tipos cujo tamanho &#233; semelhante ao de um pequeno comprimido&#41;&#44; poder&#225; vir a ser justific&#225;vel nalguns doentes &#40;de maior risco emb&#243;lico&#44; com <span class="elsevierStyleItalic">scores</span> de CHADS2 mais elevados&#41; a implanta&#231;&#227;o profil&#225;tica destes dispositivos&#46; A dete&#231;&#227;o de epis&#243;dios assintom&#225;ticos poderia levar a institui&#231;&#227;o mais precoce de hipocoagula&#231;&#227;o&#44; ou mesmo a altera&#231;&#227;o nas estrat&#233;gias de controlo de ritmo &#40;com f&#225;rmacos antiarr&#237;tmicos ou abla&#231;&#227;o&#41; que poderiam ser aplicadas mais cedo&#44; o que teria impacto na evolu&#231;&#227;o da doen&#231;a&#46;</p></span></span>
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Recommended article of the month
Comment on «Subclinical atrial fibrillation and the risk of stroke»
Diogo Magalhães Cavaco
Member of the Editorial Board of the Revista Portuguesa de Cardiologia
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      <span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia><span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Abstract</span></p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Background&#58;</span> One quarter of strokes are of unknown cause&#44; and subclinical atrial fibrillation may be a common etiologic factor&#46; Pacemakers can detect subclinical episodes of rapid atrial rate&#44; which correlate with electrocardiographically documented atrial fibrillation&#46; We evaluated whether subclinical episodes of rapid atrial rate detected by implanted devices were associated with an increased risk of ischemic stroke in patients who did not have other evidence of atrial fibrillation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Methods&#58;</span> We enrolled 2580 patients&#44; 65 years of age or older&#44; with hypertension and no history of atrial fibrillation&#44; in whom a pacemaker or defibrillator had recently been implanted&#46; We monitored the patients for 3 months to detect subclinical atrial tachyarrhythmias &#40;episodes of atrial rate &#62;190 beats per minute for more than 6<span class="elsevierStyleHsp" style=""></span>minutes&#41; and followed them for a mean of 2&#46;5 years for the primary outcome of ischemic stroke or systemic embolism&#46; Patients with pacemakers were randomly assigned to receive or not to receive continuous atrial overdrive pacing&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Results&#58;</span> By 3 months&#44; subclinical atrial tachyarrhythmias detected by implanted devices had occurred in 261 patients &#40;10&#46;1&#37;&#41;&#46; Subclinical atrial tachyarrhythmias were associated with an increased risk of clinical atrial fibrillation &#40;hazard ratio&#44; 5&#46;56&#59; 95&#37; confidence interval &#91;CI&#93;&#44; 3&#46;78 to 8&#46;17&#59; P&#60;0&#46;001&#41; and of ischemic stroke or systemic embolism &#40;hazard ratio&#44; 2&#46;49&#59; 95&#37; CI&#44; 1&#46;28 to 4&#46;85&#59; P&#61;0&#46;007&#41;&#46; Of 51 patients who had a primary outcome event&#44; 11 had had subclinical atrial tachyarrhythmias detected by 3 months&#44; and none had had clinical atrial fibrillation by 3 months&#46; The population attributable risk of stroke or systemic embolism associated with subclinical atrial tachyarrhythmias was 13&#37;&#46; Subclinical atrial tachyarrhythmias remained predictive of the primary outcome after adjustment for predictors of stroke &#40;hazard ratio&#44; 2&#46;50&#59; 95&#37; CI&#44; 1&#46;28 to 4&#46;89&#59; P&#61;0&#46;008&#41;&#46; Continuous atrial overdrive pacing did not prevent atrial fibrillation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conclusions&#58;</span> Subclinical atrial tachyarrhythmias&#44; without clinical atrial fibrillation&#44; occurred frequently in patients with pacemakers and were associated with a significantly increased risk of ischemic stroke or systemic embolism&#46; &#40;Funded by St&#46; Jude Medical&#59; ASSERT ClinicalTrials&#46;gov number&#44; NCT00256152&#41;&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">&lt;rohs1&gt;\n
       Coment&#225;rio\n
      &lt;/rohs1&gt;</span><p id="par0040" class="elsevierStylePara elsevierViewall">&#201; sabido que o n&#250;mero de epis&#243;dios assintom&#225;ticos de fibrilha&#231;&#227;o auricular &#233; superior ao n&#250;mero de epis&#243;dios sintom&#225;ticos&#46; Por outro lado e embora 10 a 15&#37; dos acidentes vasculares cerebrais seja atribu&#237;vel a fibrilha&#231;&#227;o auricular documentada&#44; em 25&#37; dos acidentes isqu&#233;micos n&#227;o se consegue identificar um fator etiol&#243;gico &#40;AVC criptog&#233;nico&#41;&#46; Admite-se que alguns destes AVC sejam devidos a FA subcl&#237;nica&#44; embora se desconhe&#231;a a preval&#234;ncia e o progn&#243;stico desta entidade&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">O estudo ASSERT &#40;&#171;Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial&#187;&#41; incluiu 2500 doentes hipertensos com mais que 65 anos submetidos a implanta&#231;&#227;o de <span class="elsevierStyleItalic">pacemaker</span>&#47;CDI de dupla c&#226;mara&#46; Doentes com hist&#243;ria de FA&#47;<span class="elsevierStyleItalic">flutter</span> documentados ou doentes sob hipocoagula&#231;&#227;o oral foram exclu&#237;dos do estudo&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">O estudo tinha 2 objetivos prim&#225;rios&#58; &#40;1&#41; &#8211; a avalia&#231;&#227;o da associa&#231;&#227;o entre epis&#243;dios assintom&#225;ticos de fibrilha&#231;&#227;o auricular e o risco de AVC isqu&#233;mico e &#40;2&#41; &#8211; a avalia&#231;&#227;o da efic&#225;cia de <span class="elsevierStyleItalic">pacing</span> auricular mais r&#225;pido do que o ritmo intr&#237;nseco do doente <span class="elsevierStyleItalic">&#40;overdrive pacing&#41;</span> na preven&#231;&#227;o de epis&#243;dios cl&#237;nicos de fibrilha&#231;&#227;o auricular&#46; No seguimento&#44; a interroga&#231;&#227;o dos aparelhos documentava se tinham ou n&#227;o existido epis&#243;dios de arritmias auriculares &#40;definidos para o ensaio como a ocorr&#234;ncia de frequ&#234;ncias auriculares superiores a 190&#47;min durante pelo menos 6 minutos&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Os resultados deste estudo mostram que o n&#250;mero de epis&#243;dios nesta popula&#231;&#227;o &#233; elevado &#8211; aos 3 meses de seguimento&#44; em 10&#44;1&#37; dos doentes tinham existido epis&#243;dios assintom&#225;ticos de fibrilha&#231;&#227;o auricular &#40;com uma mediana de 2 epis&#243;dios&#47;doente&#41;&#46; Apenas em 0&#44;03&#37; &#40;7 doentes&#41; ocorreram epis&#243;dios sintom&#225;ticos&#46; Num seguimento m&#233;dio de 2&#44;5 anos ocorreram arritmias auriculares em mais 24&#44;5&#37; dos doentes&#46; Houve epis&#243;dios de fibrilha&#231;&#227;o auricular sintom&#225;tica em mais doentes que tinham tido arritmias assintom&#225;ticas nos primeiros 3 meses &#40;15&#44;7 <span class="elsevierStyleItalic">versus</span> 3&#44;1&#37;&#44; HR 5&#44;56&#44; p &#60; 0&#44;01&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Durante o seguimento&#44; 4&#44;2&#37; dos doentes com arritmias auriculares assintom&#225;ticas nos primeiros 3 meses tiveram AVC isqu&#233;mico &#40;1&#44;69&#37;&#47;ano&#41;&#44; n&#250;mero significativamente superior do que nos doentes sem arritmias subcl&#237;nicas &#40;1&#44;7&#37;&#44; 0&#44;69&#37;&#47;ano&#41;&#46; O risco &#40;HR 2&#44;5&#44; p &#60; 0&#44;01&#41; manteve-se semelhante ap&#243;s ajuste para os fatores de risco basal de ambos os grupos&#46; Do total de doentes com AVC isqu&#233;mico&#44; 21&#37; tinha tido epis&#243;dios assintom&#225;ticos de arritmias auriculares e nenhum tido FA cl&#237;nica&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Estes resultados s&#227;o importantes&#44; porque estabelecem uma associa&#231;&#227;o clara entre epis&#243;dios assintom&#225;ticos de fibrilha&#231;&#227;o auricular e o acidente vascular cerebral&#46; Esta associa&#231;&#227;o&#44; embora do ponto de vista fisiopatol&#243;gico parecesse ser evidente&#44; n&#227;o tinha sido demonstrada at&#233; hoje num grande ensaio cl&#237;nico&#46; Estas arritmias surgem muito esporadicamente &#40;mediana de tempo at&#233; primeiro epis&#243;dio de 35 dias&#41; &#8211; o que faz com que os m&#233;todos de diagn&#243;stico convencional &#40;Holter de 24<span class="elsevierStyleHsp" style=""></span>h ou mesmo Holters de 5-7 dias&#41; tenham muito pouco valor no seu diagn&#243;stico&#46; Por outro lado&#44; demonstra ainda que mesmo epis&#243;dios de curta dura&#231;&#227;o de fibrilha&#231;&#227;o auricular t&#234;m implica&#231;&#227;o no que diz respeito a fen&#243;menos emb&#243;licos&#46; Parece haver uma tend&#234;ncia para que epis&#243;dios de mais longa dura&#231;&#227;o tenham um risco superior de embolia&#44; embora os autores reconhe&#231;am que n&#227;o h&#225; poder estat&#237;stico no ensaio para o demonstrar&#46; Por outro lado&#44; &#233; tamb&#233;m poss&#237;vel especular que&#44; se a dura&#231;&#227;o escolhida para a defini&#231;&#227;o dos epis&#243;dios de fibrilha&#231;&#227;o fosse mais baixa &#40;inferior a 6 minutos&#41;&#44; n&#227;o s&#243; o n&#250;mero de epis&#243;dios seria maior mas&#44; provavelmente o risco emb&#243;lico se manteria elevado&#46; Outro aspeto interessante &#233; que o <span class="elsevierStyleItalic">score</span> de CHADS2 modula o risco emb&#243;lico tamb&#233;m nesta situa&#231;&#227;o &#8211; quanto maior o n&#250;mero de fatores de risco&#44; maior o risco emb&#243;lico&#44; demonstrando&#44; uma vez mais&#44; o enorme poder preditivo deste &#237;ndice de aplica&#231;&#227;o simples&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">N&#227;o h&#225; qualquer refer&#234;ncia no estudo a uma associa&#231;&#227;o temporal entre os epis&#243;dios detetados e os fen&#243;menos emb&#243;licos observados&#46; Fica assim por esclarecer se os epis&#243;dios assintom&#225;ticos detetados precedem por horas ou dias os fen&#243;menos emb&#243;licos&#44; ou se h&#225; sequer alguma rela&#231;&#227;o temporal&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Em rela&#231;&#227;o ao segundo objetivo do estudo &#8211; n&#227;o houve qualquer diferen&#231;a em rela&#231;&#227;o ao n&#250;mero de epis&#243;dios de arritmias auriculares nos doentes com o algoritmo de <span class="elsevierStyleItalic">overdrive pacing</span> ativado&#46; Este resultado n&#227;o &#233; muito diferente do que tem sido encontrado noutros ensaios cl&#237;nicos destes algoritmos&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">O presente estudo traz&#44; assim&#44; novas informa&#231;&#245;es importantes sobre a associa&#231;&#227;o entre fibrilha&#231;&#227;o auricular &#40;mesmo que assintom&#225;tica e mesmo que de curta dura&#231;&#227;o&#41; e o acidente vascular emb&#243;lico&#46; &#201; poss&#237;vel que este conhecimento venha a trazer altera&#231;&#245;es na interven&#231;&#227;o diagn&#243;stica e terap&#234;utica destes doentes&#46; Com o desenvolvimento da tecnologia e com registadores de eventos implant&#225;veis cada vez menores &#40;h&#225; j&#225; prot&#243;tipos cujo tamanho &#233; semelhante ao de um pequeno comprimido&#41;&#44; poder&#225; vir a ser justific&#225;vel nalguns doentes &#40;de maior risco emb&#243;lico&#44; com <span class="elsevierStyleItalic">scores</span> de CHADS2 mais elevados&#41; a implanta&#231;&#227;o profil&#225;tica destes dispositivos&#46; A dete&#231;&#227;o de epis&#243;dios assintom&#225;ticos poderia levar a institui&#231;&#227;o mais precoce de hipocoagula&#231;&#227;o&#44; ou mesmo a altera&#231;&#227;o nas estrat&#233;gias de controlo de ritmo &#40;com f&#225;rmacos antiarr&#237;tmicos ou abla&#231;&#227;o&#41; que poderiam ser aplicadas mais cedo&#44; o que teria impacto na evolu&#231;&#227;o da doen&#231;a&#46;</p></span></span>
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Revista Portuguesa de Cardiologia (English edition)
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