Brady- and tachyarrhythmias detected by continuous rhythm monitoring in paroxysmal atrial fibrillation

Objective Atrial fibrillation (AF) is associated with adverse events including conduction disturbances, ventricular arrhythmias and sudden death. The aim of this study was to examine brady-and tachyarrhythmias using continuous rhythm monitoring in patients with paroxysmal self- terminating AF (PAF).Methods In this multicentre observational substudy to the Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling and Vascular destabilisation in the progression of AF (RACE V), we included 392 patients with PAF and at least 2 years of continuous rhythm monitoring. All patients received an implantable loop recorder, and all detected episodes of tachycardia =182 beats per minute (BPM), bradycardia =30 BPM or pauses =5 s were adjudicated by three physicians.Results Over 1272 patient- years of continuous rhythm monitoring, we adjudicated 1940 episodes in 175 patients (45%): 106 (27%) patients experienced rapid AF or atrial flutter (AFL), pauses =5 s or bradycardias =30 BPM occurred in 47 (12%) patients and in 22 (6%) patients, we observed both episode types. No sustained ventricular tachycardias occurred. In the multivariable analysis, age >70 years (HR 2.3, 95% CI 1.4 to 3.9), longer PR interval (HR 1.9, 1.1-3.1), CHA2DS2- VASc score =2 (HR 2.2, 1.1-4.5) and treatment with verapamil or diltiazem (HR 0.4, 0.2-1.0) were significantly associated with bradyarrhythmia episodes. Age >70 years was associated with lower rates of tachyarrhythmias.Conclusions In a cohort exclusive to patients with PAF, almost half experienced severe bradyarrhythmias or AF/ AFL with rapid ventricular rates. Our data highlight a higher than anticipated bradyarrhythmia risk in PAF.