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1119 Permanent AF was associated with age at baseline, with the risk increasing 2‐fold for each decade of life, as well as with male sex. In this retrospective study, the position of RV lead or the type of pacing were not related with per‐ manent AF. The authors highlight the need for follow ‐up to evaluate the onset of AF that would enable prompt reaction. Unfortunately, the study was not based on continuous cardiac rhythm monitoring since many implanted pacemakers had no automated storage of intracardiac elec‐ trocardiograms and most of them were not ca‐ pable of detecting AF. The extended diagnostic capabilities of modern pacemakers allow contin‐ uous monitoring of the cardiac rhythm and ap‐ propriate detection of atrial tachyarrhythmias known as atrial high ‐rate episodes (AHREs).6 AHREs, currently defined as episodes of at least 5 minutes of atrial tachyarrhythmias, also including AF, with an atrial rate higher than 175 to 180 bpm, are found on follow ‐up at rou‐ tine device check or at remote monitoring, and classified in terms of duration of a single epi‐ sode or time spent in atrial tachyarrhythmias during a day.5,7 The extended diagnostic capabilities of im‐ planted devices have led to new terms, such as AF burden, defined as the overall time spent in AF during a specified period of time, and sub‐ clinical AF, defined as episodes of atrial tachyar‐ rhythmias with their duration between 5 min‐ utes and 24 hours, detected by a cardiac implant‐ able electronic device in patients without clini‐ cal history or symptoms of AF.8,9 In the ASSERT study (Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemak‐ er Patients and the Atrial Fibrillation Reduction Atrial fibrillation (AF) is the most common ar‐ rhythmia encountered in clinical practice, and even if it is usually associated with palpitations, it frequently may be asymptomatic (up to 40% of cases)1 or it may present atypical symptoms (around 25% of cases).2 Asymptomatic AF is re‐ ported to be more prevalent in men, older pa‐ tients, and those with permanent AF. Moreover, it is usually associated with more complex co‐ morbidities and an increased risk of thrombo‐ embolism as well as cardiovascular and all ‐cause mortality, as compared with symptomatic AF.1,2 In the current issue of Kardiologia Polska (Kardiol Pol, Polish Heart Journal), Dębski et al3 report on an interesting retrospective study that eval‐ uated the incidence of permanent AF in a cohort of 3932 patients implanted with a dual ‐chamber pacemaker, analyzed the predictors of perma‐ nent AF development, and considered the im‐ pact of AF on patients’ outcome. The setting of the study is quite interesting since pacemakers with an atrial lead enable a precise and detailed assessment of presence or absence of atrial tachyarrhythmia and allow to quantify, in terms of AF burden, the time spent in AF, as well as the evolution or progression of the arrhythmia, independently of the presence of symptoms or their absence.4,5 During a follow ‐up of 4.6 years, 19% of pa‐ tients developed permanent AF and at year 1, 5, 10, and 15 after device implantation, permanent AF was found in 4.4%, 13.3%, 25%, and 32.3% of patients, respectively. This indicates that with time, the burden of AF, either symptomatic or asymptomatic, is substantial, and needs for ap‐ propriate decision ‐making, first of all, to start oral anticoagulation in patients at risk. Correspondence to: Prof. Giuseppe Boriani, PhD, Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41 121 Modena, Italy, phone: +39 059 422 5836, email: giuseppe.boriani@unimore.it Received: October 19, 2019. Accepted: October 21, 2019. Published online: December 19, 2019. Kardiol Pol. 2019; 77 (12): 1119-1120 doi:10.33963/KP.15110 Copyright by the Author(s), 2019 E D I T O R I A L

Atrial fibrillation in patients with cardiac implantable electronic devices: new perspectives with important clinical implications