Long-term rhythm monitoring with an implantable loop recorder in patients after the first clinical atrial fibrillation episode. Towards an individualized management

Although atrial fibrillation (AF) is an arrhythmia with a variable clinical profile (symptomatic and asymptomatic episodes), the first symptomatic episode leads to its initial diagnosis in most cases. Nowadays, continuous and remote long-term cardiac rhythm monitoring is feasible by the use of implantable loop recorders. The data concerning the AF recurrences and progression after the first electrocardiographic-documented clinical AF episode demonstrates that a high percentage of patients may not suffer any other AF recurrence, or may present a low recurrence rate of the arrhythmia in the future. The AF burden may play a key role in the management of the arrhythmia as far as the decision-making for anticoagulation, rate and/or rhythm control therapy is concerned. There is evidence that a higher AF burden is associated with a higher risk of ischemic stroke. Non-vitamin K antagonists (NOACs) anticoagulants are increasingly used in the management of AF, providing a more predictable effect with rapid onset and offset of their action. The use of these agents in combination with devices that provide a continuous remote rhythm monitoring capability has encouraged anticoagulation strategies based on the AF burden. Data from tailored anticoagulation studies in AF are in favor of the long-term rhythm monitoring, ensuring a patient-centered approach with a better evaluation and more individualized management of AF, especially in patients with intermediate thromboembolic risk and high bleeding risk. Further large randomized trials are needed, not only to evaluate such strategies but also to elucidate the long-term cardiac rhythm monitoring in the AF management.