Net Benefit of Anticoagulation in Subclinical Device-Detected Atrial Fibrillation

IMPORTANCE: The role of anticoagulation for stroke prevention in patients with device-detected atrial high-rate episodes (subclinical atrial fibrillation [AF]) is a subject of equipoise. OBJECTIVE: To assess the net benefit of non–vitamin K antagonist oral anticoagulants (NOACs) in patients with device-detected subclinical AF. DESIGN, SETTING, AND PARTICIPANTS: A Markov decision model (October 1, 2024) compared 10 000 patients with anticoagulation vs 10 000 without, with stroke and bleeding risks similar to those in randomized trials of anticoagulation in subclinical AF. Anticoagulation was modeled to decrease ischemic stroke risk by 32% and increase major bleeding risk by 62%. MAIN OUTCOMES AND MEASURES: Cumulative quality-adjusted life-years (QALYs) over a 10-year simulation. RESULTS: In two cohorts of 10 000 patients (mean age, 77 years; 37% women), NOAC therapy was associated with 233 fewer ischemic strokes (21.7%), 55 fewer deaths (1.1%), and 453 more major bleeding events (37.3%) over 10 years. Per patient, this translated to approximately 1 additional quality-adjusted week of life (0.024 QALYs) with NOAC treatment. In probabilistic sensitivity analysis, there was a 65.8% probability that NOAC treatment yielded more QALYs than withholding treatment. CONCLUSIONS AND RELEVANCE: In this decision analytical model, initiating NOACs in device-detected subclinical AF was associated with a minimal increase in QALYs; benefits were uncertain and the overall net benefit does not appear clinically meaningful.