CONTENT

To the Editor,

In light of the increasing relevance of atrial fibrillation (AF) burden in stroke prevention strategies, the recent study by Yurtseven et al¹ merits further reflection. Their investigation into nonsustained AF (NS-AF) episodes—defined as <30 seconds in duration—recorded by 24-hour Holter monitoring, and their association with long-term thromboembolic events, provides a crucial contribution to a previously ambiguous area of arrhythmia management.

We commend the authors for 3 important contributions. First, their inclusion of a real-world cohort with CHA₂ DS₂-VA risk stratification lends strong clinical applicability to the findings. Second, they focus on NS-AF episodes that are often dismissed as benign or clinically insignificant, especially in fast-paced settings such as emergency departments (EDs). Third, they highlight the high incidence of thromboembolic events in patients with CHA₂ DS₂-VA scores ≥2, reaching 38.5% in those with a score of 4, challenging longstanding assumptions in acute care decision-making.

That said, we believe this study also underscores three critical implications for emergency medicine that warrant emphasis.

First, ED physicians frequently encounter patients presenting with palpitations, near-syncope, or transient neurological symptoms, which are often evaluated with brief ECGs or single-day Holter monitoring.^2,3 In such cases, short, irregularly irregular rhythms under 30 seconds are routinely overlooked or dismissed. This study compels us to reexamine that reflex.

Second, the recent ESC guidelines have removed the minimum duration criterion for AF diagnosis, further blurring the operational definition of AF in acute care.⁴ Yurtseven et al’s findings give practical weight to this conceptual shift by demonstrating that even brief arrhythmias in high-risk patients may portend thromboembolic events.

Third, their results suggest that CHA₂ DS₂-VA scores retain predictive validity for thromboembolic risk at a threshold of ≥2 even in the absence of sustained AF. This has implications for risk stratification and safe discharge planning in EDs, particularly in resource-limited settings where access to long-term cardiac monitoring may be delayed or unavailable. Of note, the negative predictive value of CHA₂ DS₂-VA <2 reached 95.5%, further supporting this threshold as clinically actionable.

In summary, Yurtseven et al’s study provides data-driven justification for a more cautious and proactive approach in ED patients with short AF episodes and high thromboembolic risk. This includes stronger consideration for early cardiology referral, prolonged monitoring, or risk-informed follow-up pathways. We thank the authors for bringing attention to a clinically relevant, yet underrecognized subset of arrhythmia-related risk, and hope their findings inspire further prospective validation in acute care cohorts.

Footnotes

Declaration of Interests: The authors have no conflicts of interest to declare.

References

1. Yurtseven E, Ural D, Karaüzüm K. Nonsustained atrial fibrillation in Ambulatory ECG Recording and thromboembolic Events in Long term Follow-Up. Anatol J Cardiol. 2025;29(8):401-408.
2. Long B, Robertson J, Koyfman A, Maliel K, Warix JR. Emergency medicine considerations in atrial fibrillation. Am J Emerg Med. 2018;36(6):1070-1078.
3. Long B, Brady WJ, Gottlieb M. Emergency medicine updates: atrial fibrillation with rapid ventricular response. Am J Emerg Med. 2023;74():57-64.
4. Van Gelder IC, Rienstra M, Bunting KV. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3314-3414.