Targeted Anticoagulation for Atrial Fibrillation Guided by Continuous Rhythm Assessment With an Insertable Cardiac Monitor: The Rhythm Evaluation for Anticoagulation With Continuous Monitoring (REACT.COM) Pilot Study.
Level 4 - case-series / case-control
Single-arm prospective interventional pilot study without a control group
PubMed 26511221 · doi:10.1111/jce.12864
What was done
This multicenter, single-arm pilot study (REACT.COM) evaluated intermittent novel oral anticoagulant (NOAC) therapy guided by continuous rhythm monitoring via insertable cardiac monitors (ICM). Patients with nonpermanent atrial fibrillation (AF) and a CHADS2 score of 1 or 2 on a NOAC completed a 60-day run-in. If no AF episode ≥1 hour occurred, NOACs were discontinued and only reinitiated for 30 days following any ICM-detected AF episode ≥1 hour identified through daily transmissions. Endpoints included time on NOAC, stroke, and bleeding.
What was found
Among 59 enrolled patients followed for a mean of 466 ± 131 days (24,004 transmissions; 98.7% compliance), 18 patients (31%) experienced 35 AF episodes ≥1 hour. Total time on NOACs was 1,472 days, representing a 94% reduction compared to continuous anticoagulation. There were 0 strokes, 0 deaths, 3 traumatic bleeds (all while on aspirin), and 3 potential transient ischemic attacks (all while on aspirin alone, CHADS2 score 1).
Why it matters
This study shows the technical feasibility of using continuous rhythm monitoring to guide targeted, short-term anticoagulation only after detected AF episodes. If proven safe in larger trials, this approach could substantially reduce cumulative drug exposure and bleeding risk in select low-to-intermediate risk AF patients.
Limits
The study is limited by a small sample size (n=59), lack of a randomized control arm, and restriction to patients with low-to-moderate stroke risk (CHADS2 1–2). The occurrence of three potential TIAs highlights that clinical safety regarding thromboembolic protection remains unproven.
Cited by
- supports The REACT clinical trial is investigating whether patients with intermittent atrial fibrillation can take anticoagulation temporarily only when episodes occur rather than on a continuous, permanent basis.