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Kohno R, Nantsupawat T, Benditt DG. Trends in Subcutaneous Cardiac Monitoring Technology. J Innov Card Rhythm Manag 2018; 9:3247-3255. [PMID: 32494499 PMCID: PMC7252872 DOI: 10.19102/icrm.2018.090703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/02/2018] [Indexed: 02/07/2023] Open
Abstract
Ambulatory cardiac monitoring is a rapidly expanding field and one that is likely to progress beyond electrocardiographic (ECG) and blood pressure recordings. To date, the primary cardiac monitoring focus has been ambulatory ECG (AECG) monitoring. In this setting, AECG monitoring has become a diagnostic tool used daily by physicians of many specialties. In this regard, both wearable and subcutaneous ECG monitoring technologies are now widely available, with the appropriate choice for a given patient being best determined by the frequency with which the patient’s symptom recurrences are expected. In other words, the less frequent the symptomatic events, then the longer the monitoring duration requirement should be. However, multiple factors other than the technology used impact success. For example, wearable AECG systems are only capable of monitoring patients for a period of a few days to several weeks due to limited battery longevity, patient intolerance to cutaneous ECG electrodes, the cumbersome nature of the device, or a combination of these factors. Current-generation insertable cardiac monitors (ICMs), on the other hand, offer three years of monitoring and infrequent skin irritation. Additionally, automatic remote download, a valuable feature in many cases, is only offered by certain wearable technologies, but is an option in all currently available ICMs. This report focuses on the current status of subcutaneous ICMs and their indications and limitations. The goal is to highlight the variety of utility of current ICM technologies and to provide insight into potential future subcutaneous ICM applications.
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Affiliation(s)
- Ritsuko Kohno
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Teerapat Nantsupawat
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - David G Benditt
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
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Ricci B, Chang AD, Hemendinger M, Dakay K, Cutting S, Burton T, Mac Grory B, Narwal P, Song C, Chu A, Mehanna E, McTaggart R, Jayaraman M, Furie K, Yaghi S. A Simple Score That Predicts Paroxysmal Atrial Fibrillation on Outpatient Cardiac Monitoring after Embolic Stroke of Unknown Source. J Stroke Cerebrovasc Dis 2018; 27:1692-1696. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.01.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/04/2018] [Accepted: 01/29/2018] [Indexed: 10/17/2022] Open
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Pedersen KB, Madsen C, Sandgaard NCF, Diederichsen ACP, Bak S, Brandes A. Subclinical atrial fibrillation in patients with recent transient ischemic attack. J Cardiovasc Electrophysiol 2018; 29:707-714. [PMID: 29478291 DOI: 10.1111/jce.13470] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/06/2018] [Accepted: 01/26/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a major risk factor of stroke, but the association between AF and transient ischemic attack (TIA) is less clear. Despite this, patients with TIA are included in stroke trials. AIMS To determine the 1-year incidence of AF in TIA patients using an insertable cardiac monitor (ICM); second, to determine factors associated with incident AF in these patients. METHODS Prospective cohort study of patients with TIA with normal standard electrocardiogram (ECG) and 72-hour Holter monitoring (HM). Exclusion criteria were as follows: age < 18 or > 81 years; prior AF/stroke; ongoing oral anticoagulation therapy or contraindication for it; significant carotid artery stenosis; uncertain TIA diagnosis. Eligible patients received an ICM and were followed for 12 months. RESULTS From November 2013 to October 2015, 809 patients were diagnosed with TIA. In total, 235 patients were eligible. Nine (3.8%) of these had AF on standard ECG or HM. Of the remaining patients, 121 refused ICM implantation. In total, 105 patients (median age 65.4 years [range 27.1-80.8], 46% males) received an ICM, which revealed AF in 7 (6.7%). Factors associated with new-onset AF were a history of recurrent TIA (odds ratio [OR] 11.5, 95% confidence interval [CI] 2.1-63.6) and heart failure (OR 12.7, 95% CI 1.71-96.83). CONCLUSIONS The 1-year incidence of AF in TIA patients with normal ECG and HM was 6.7% using an ICM. Factors associated with development of AF were recurrent TIA and heart failure.
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Affiliation(s)
| | - Charlotte Madsen
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | | | | | - Søren Bak
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense, Denmark
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Sanna T, Ziegler PD, Crea F. Detection and management of atrial fibrillation after cryptogenic stroke or embolic stroke of undetermined source. Clin Cardiol 2018; 41:426-432. [PMID: 29569253 DOI: 10.1002/clc.22876] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/13/2017] [Accepted: 12/19/2017] [Indexed: 12/27/2022] Open
Abstract
Cryptogenic stroke (CS) and embolic stroke of unknown source (ESUS) represent a major challenge to healthcare systems worldwide. Atrial fibrillation (AF) is commonly found after CS or ESUS. Independent of the mechanism of the index CS or ESUS, detection of AF in these patients offers the opportunity to reduce the risk of stroke recurrence by prescribing an anticoagulant instead of aspirin. The detection of AF may be pursued with different monitoring strategies. Comparison of monitoring strategies should take into account that AF detection rates reported in published studies, and then pooled in meta-analyses, are not only a function of the monitoring strategy itself, but also depend on patient-related, device-related, and study design-related factors. Once AF is found, the decision to anticoagulate a patient should be made on the basis of AF burden and the baseline risk of the patient. Empirical anticoagulation in patients with ESUS and no evidence of AF is an intriguing but still-unproven strategy and therefore should not be adopted outside of randomized clinical trials.
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Affiliation(s)
- Tommaso Sanna
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Paul D Ziegler
- Diagnostics Research, Medtronic Inc., Mounds View, Minnesota
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
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Quantifying Time in Atrial Fibrillation and the Need for Anticoagulation. Prog Cardiovasc Dis 2018; 60:537-541. [DOI: 10.1016/j.pcad.2017.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 12/11/2017] [Indexed: 12/21/2022]
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Carrazco C, Golyan D, Kahen M, Black K, Libman RB, Katz JM. Prevalence and Risk Factors for Paroxysmal Atrial Fibrillation and Flutter Detection after Cryptogenic Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 27:203-209. [PMID: 29032886 DOI: 10.1016/j.jstrokecerebrovasdis.2017.08.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 08/04/2017] [Accepted: 08/14/2017] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Long-term cardiac monitoring with implantable loop recorders (ILRs) has revealed occult paroxysmal atrial fibrillation and flutter (PAF) in a substantial minority of cryptogenic ischemic stroke (CIS) patients. Herein, we aim to define the prevalence, clinical relevance, and risk factors for PAF detection following early poststroke ILR implantation. MATERIALS AND METHODS A retrospective study of CIS patients (n = 100, mean age 65.8 years; 52.5% female) who underwent ILR insertion during, or soon after, index stroke admission. Patients were prospectively followed by the study cardiac electrophysiologist who confirmed the PAF diagnosis. Univariate and multivariate analyses compared clinical, laboratory, cardiac, and imaging variables between PAF patients and non-PAF patients. RESULTS PAF was detected in 31 of 100 (31%) CIS patients, and anticoagulation was initiated in almost all (30 of 31, 96.8%). Factors associated with PAF detection include older age (mean [year] 72.9 versus 62.9; P = .003), white race (odds ratio [OR], 4.5; confidence interval [CI], 1.8-10.8; P = .001), prolonged PR interval (PR > 175 ms; OR, 3.3; CI, 1.2-9.4; P = .022), larger left atrial (LA) diameter (mean [cm] 3.7 versus 3.5; P = .044) and LA volume index (mean [cc/m2]; 30.6 versus 24.2; P = .014), and lower hemoglobin (Hb)A1c (mean [%] 6.0 versus 6.4; P = .036). Controlling for age, obesity (body mass index > 30 kg/m2; OR, 1.2; CI, 1.1-1.4; P = .033) was independently associated with PAF detection. DISCUSSION PAF was detected with high prevalence following early postcryptogenic stroke ILR implantation and resulted in significant management changes. Older age, increased PR interval, LA enlargement, and lower HbA1c are significantly associated with PAF detection. Controlling for age, obesity is an independent risk factor. A larger prospective study is warranted to confirm these findings.
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Affiliation(s)
- Claire Carrazco
- Department of Neurology, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Daniel Golyan
- Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Michael Kahen
- Department of Neurology, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Karen Black
- Department of Radiology, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Richard B Libman
- Department of Neurology, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Jeffrey M Katz
- Department of Neurology, North Shore University Hospital, Northwell Health, Manhasset, New York; Department of Radiology, North Shore University Hospital, Northwell Health, Manhasset, New York.
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Gorenek B, Bax J, Boriani G, Chen SA, Dagres N, Glotzer TV, Healey JS, Israel CW, Kudaiberdieva G, Levin LÅ, Lip GYH, Martin D, Okumura K, Svendsen JH, Tse HF, Botto GL, Sticherling C, Linde C, Kutyifa V, Bernat R, Scherr D, Lau CP, Iturralde P, Morin DP, Savelieva I, Lip G, Gorenek B, Sticherling C, Fauchier L, Goette A, Jung W, Vos MA, Brignole M, Elsner C, Dan GA, Marin F, Boriani G, Lane D, Lundqvist CB, Savelieva I. Device-detected subclinical atrial tachyarrhythmias: definition, implications and management—an European Heart Rhythm Association (EHRA) consensus document, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Europace 2017; 19:1556-1578. [DOI: 10.1093/europace/eux163] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/04/2017] [Indexed: 01/03/2023] Open
Affiliation(s)
| | - Jeroen Bax
- Leiden University Medical Center (Lumc), Leiden, the Netherlands
| | - Giuseppe Boriani
- Cardiology Department, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
| | - Shih-Ann Chen
- Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Electrophysiology, University Leipzig – Heart Center, Leipzig, Germany
| | - Taya V Glotzer
- Hackensack University Medical Center, Hackensack, NJ, USA
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - David Martin
- Lahey Hospital and Medical Center, Burlington, MA, USA
| | | | | | - Hung-Fat Tse
- Cardiology Division, Department of Medicine; The University of Hong Kong, Hong Kong
| | | | | | | | | | | | | | | | | | - Daniel P Morin
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, USA
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Freedman B, Boriani G, Glotzer TV, Healey JS, Kirchhof P, Potpara TS. Management of atrial high-rate episodes detected by cardiac implanted electronic devices. Nat Rev Cardiol 2017; 14:701-714. [DOI: 10.1038/nrcardio.2017.94] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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60
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Ziegler PD, Rogers JD, Ferreira SW, Nichols AJ, Richards M, Koehler JL, Sarkar S. Long-term detection of atrial fibrillation with insertable cardiac monitors in a real-world cryptogenic stroke population. Int J Cardiol 2017. [PMID: 28624331 DOI: 10.1016/j.ijcard.2017.06.039] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The long-term incidence of atrial fibrillation (AF) in cryptogenic stroke (CS) patients has been explored in carefully controlled clinical trials but real-world data are limited. We investigated the two-year incidence of AF in real-world clinical practice among a large cohort of patients with an insertable cardiac monitor (ICM) placed for AF detection following CS. METHODS Patients in the de-identified Medtronic Discovery™ Link database who received an ICM (Reveal LINQ™) for the purpose of AF detection following CS were included and monitored for up to 2years. All detected AF episodes (≥2min) were adjudicated. We quantified the AF detection rate using Kaplan-Meier survival estimates, analyzed the median time to initial detection of AF, and simulated the ability of various intermittent monitoring strategies to detect AF. RESULTS A total of 1247 patients (65.3±13.0years, 53% male) were included and followed for 579±222days. AF episodes (n=4183) were detected in 238 patients, resulting in an AF detection rate of 21.5% at 2years. The median time to AF detection was 112 [IQR 35-293] days. Intermittent monitoring for AF detection was inferior to continuous ICM monitoring with sensitivities ranging from 2.9% (annual 24-hour Holter) to 29.9% (quarterly 7-day Holters), p<0.001. CONCLUSIONS AF episodes were detected via continuous monitoring with ICMs in approximately 1 of every 5 CS patients within 2years of follow-up. The vast majority of patients with AF would not have been detected with conventional external ambulatory monitors. ICMs should therefore be considered in the evaluation of CS patients.
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Affiliation(s)
- Paul D Ziegler
- Medtronic Cardiac Rhythm Heart Failure, Mounds View, MN, United States.
| | | | | | - Allan J Nichols
- OhioHealth Heart & Vascular Physicians, Columbus, OH, United States
| | - Mark Richards
- ProMedica Physicians Cardiology, Toledo, OH, United States
| | - Jodi L Koehler
- Medtronic Cardiac Rhythm Heart Failure, Mounds View, MN, United States
| | - Shantanu Sarkar
- Medtronic Cardiac Rhythm Heart Failure, Mounds View, MN, United States
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Diederichsen SZ, Haugan KJ, Køber L, Højberg S, Brandes A, Kronborg C, Graff C, Holst AG, Nielsen JB, Krieger D, Svendsen JH. Atrial fibrillation detected by continuous electrocardiographic monitoring using implantable loop recorder to prevent stroke in individuals at risk (the LOOP study): Rationale and design of a large randomized controlled trial. Am Heart J 2017; 187:122-132. [PMID: 28454796 DOI: 10.1016/j.ahj.2017.02.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 02/06/2017] [Indexed: 02/05/2023]
Abstract
Atrial fibrillation (AF) increases the rate of stroke 5-fold, and AF-related strokes have a poorer prognosis compared with non-AF-related strokes. Atrial fibrillation and stroke constitute an intensifying challenge, and health care organizations are calling for awareness on the topic. Previous studies have demonstrated that AF is often asymptomatic and consequently undiagnosed. The implantable loop recorder (ILR) allows for continuous, long-term electrocardiographic monitoring with daily transmission of arrhythmia information, potentially leading to improvement in AF detection and stroke prevention. METHODS The LOOP study is an investigator-initiated, randomized controlled trial with 6,000 participants randomized 3:1 to a control group or to receive an ILR with continuous electrocardiographic monitoring. Participants are identified from Danish registries and are eligible for inclusion if 70years or older and previously diagnosed as having at least one of the following conditions: hypertension, diabetes mellitus, heart failure, or previous stroke. Exclusion criteria include history of AF and current oral anticoagulation treatment. When an AF episode lasting ≥6minutes is detected, oral anticoagulation will be initiated according to guidelines. Expected follow-up is 4years. The primary end point is time to stroke or systemic embolism, whereas secondary end points include time to AF diagnosis and death. CONCLUSION The LOOP study will evaluate health benefits and cost-effectiveness of ILR as a screening tool for AF to prevent stroke in patients at risk. Secondary objectives include identification of risk factors for the development of AF and characterization of arrhythmias in the population. The trial holds the potential to influence the future of stroke prevention.
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Affiliation(s)
- Søren Zöga Diederichsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ketil Jørgen Haugan
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Højberg
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christian Kronborg
- Centre of Health Economics Research (COHERE), Department of Business and Economics, University of Southern Denmark, Odense, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Anders Gaarsdal Holst
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; The Danish National Research Foundation Center for Cardiac Arrhythmia, Copenhagen, Denmark
| | - Jonas Bille Nielsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Derk Krieger
- University Hospital Zurich, Switzerland; Mediclinic City Hospital, Dubai, United Arabic Emirates
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; The Danish National Research Foundation Center for Cardiac Arrhythmia, Copenhagen, Denmark.
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Dilaveris PE, Kennedy HL. Silent atrial fibrillation: epidemiology, diagnosis, and clinical impact. Clin Cardiol 2017; 40:413-418. [PMID: 28273368 DOI: 10.1002/clc.22667] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 11/23/2016] [Indexed: 11/05/2022] Open
Abstract
Silent or subclinical asymptomatic atrial fibrillation (SAF) has currently gained wide interest in the epidemiologic, neurologic, and cardiovascular communities. It is well known that the electrophysiological and mechanical effects of symptomatic and silent atrial fibrillation (AF) are the same. It is probable that because "AF begets AF," progression from paroxysmal to persistent or permanent AF might be more rapid in patients with long-term unrecognized and untreated SAF, because no treatment is sought by or provided to such patients. Moreover, SAF is common and has significant clinical implications. The clinical consequences of SAF, which include emboli (silent or symptomatic), heart failure, and early mortality, are of paramount importance. Consequently, SAF should be considered in estimating the prevalence of the disease and its impact on morbidity, mortality, and quality of life. Several diagnostic methods of arrhythmia detection utilizing the surface electrocardiogram (ECG), subcutaneous ECG, or intracardiac devices have been utilized to seek meaningful arrhythmic markers of SAF. Whereas a wide range of clinical risk factors of SAF have been validated in the literature, there is an ongoing search for those arrhythmic risk factors that precisely identify and prognosticate outcome events in diverse populations at risk of SAF. Modern diagnostic modalities for the identification of SAF exist, but should be further explored, validated, and tailored to each patient needs. The scientific community should undertake the clinical challenge of identifying and treating SAF.
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Affiliation(s)
| | - Harold L Kennedy
- Department of Medicine & Cardiovascular Diseases, University of Missouri, Columbia, Missouri.,The Cardiovascular Research Foundation, St. Louis, Missouri
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Conti S, Reiffel JA, Gersh BJ, Kowey PR, Wachter R, Halperin JL, Kaplon RE, Pouliot E, Verma A. Baseline Demographics, Safety, and Patient Acceptance of an Insertable Cardiac Monitor for Atrial Fibrillation Screening: The REVEAL-AF Study. J Atr Fibrillation 2017; 9:1551. [PMID: 29250279 DOI: 10.4022/jafib.1551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 01/28/2017] [Accepted: 01/29/2017] [Indexed: 11/10/2022]
Abstract
Given the high prevalence and risk of stroke associated with atrial fibrillation (AF), detection strategies have important public health implications. The ongoing prospective, single-arm, open-label, multicenter REVEAL AF trial is evaluating the incidence of previously undetected AF using an insertable cardiac monitor (ICM) in patients without prior AF or device implantation, but who could be at risk for AF due to their demographic characteristics, +/- non-specific but compatible symptoms. Enrollment required an elevated AF risk profile defined as CHADS2≥3 or CHADS2=2 plus one or more of the following: coronary artery disease, renal impairment, sleep apnea or chronic obstructive pulmonary disease. Exclusions included stroke or transient ischemic attack occurring in the previous year. Of 450 subjects screened, 399 underwent a device insertion attempt, and 395 were included in the final analysis (Reveal XT: n=122; Reveal LINQ: n=273; excluded: n=4). Participants were primarily identified by demographic characteristics and the presence of nonspecific symptoms, but without prior documentation of "overt" AF. The most common symptoms were palpitations (51%), dizziness/lightheadedness/pre-syncope (36%), and shortness of breath (36%). Over 100 subjects were enrolled in each pre-defined CHADS2 subgroup (2, 3 and ≥4). AF risk factors not included in the CHADS2 score were well represented (prevalence≥15%). Procedure and/or device related serious adverse events were low, with the miniaturized Reveal LINQ ICM having a more favorable safety profile than the predicate Reveal XT (all: n=13 [3.3%]; LINQ: n=6 [2.2%]; XT: n=7 [5.7%]). These data demonstrate that REVEAL AF was successful in enrolling its target population, high risk patients were willing to undergo ICM monitoring for AF screening, and ICM use in this group is becoming increasingly safe with advancements in technology. A clinically meaningful incidence of device detected AF in this study will inform clinical decisions regarding ICM use for AF screening in patients at risk.
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Affiliation(s)
- Sergio Conti
- Department of Cardiology, Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - James A Reiffel
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York, USA
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter R Kowey
- Department of Internal Medicine-Cardiology, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | - Rolf Wachter
- Department of Cardiology and Pneumology, University of Göttingen, Göttingen, Germany; German Cardiovascular Research Center (DZHK), Göttingen, Germany
| | - Jonathan L Halperin
- Department of Medicine-Cardiology. Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Rachelle E Kaplon
- Diagnostics, Cardiac Rhythm and Heart Failure, Medtronic, Inc. Mounds View, Minnesota, USA
| | - Erika Pouliot
- Diagnostics, Cardiac Rhythm and Heart Failure, Medtronic, Inc. Mounds View, Minnesota, USA
| | - Atul Verma
- Department of Cardiology, Southlake Regional Health Centre, Newmarket, Ontario, Canada
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Shahid F, Shantsila E, Lip GYH. Recent advances in the understanding and management of atrial fibrillation: a focus on stroke prevention. F1000Res 2016; 5:2887. [PMID: 28105320 PMCID: PMC5224684 DOI: 10.12688/f1000research.10176.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 12/29/2022] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke compared with the general population. It is anticipated that by 2030 an estimated 14-17 million patients will be diagnosed with this most prevalent arrhythmia within the European Union. AF-related stroke confers a higher mortality and morbidity risk, and thus early detection and assessment for the initiation of effective stroke prevention with oral anticoagulation (OAC) is crucial. Recent guidelines point to the use of non-vitamin K antagonist OACs (NOACs) where appropriate in stroke prevention of patients with non-valvular AF. At present, there are four NOACS available, with no direct head-to-head comparisons to suggest the superiority of one drug over another. Simple and practical risk assessment tools have evolved over the years to facilitate stroke and bleeding risk assessment in busy clinics and wards to aid decision-making. At present, the CHA 2DS 2VASc (congestive heart failure, hypertension, age 65-74/>75, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, vascular disease, female sex) score is recommended by many international guidelines as a simple and practical method of assessing stroke risk in such patients. Alongside this, use of the HAS BLED (hypertension systolic blood pressure >160 mmHg, abnormal liver/renal function [with creatinine ≥200 μmol/L], stroke, bleeding history or predisposition, labile international normalized ratio [range <60% of the time], elderly [>65], concomitant drugs/alcohol) score aims to identify patients at high risk of bleeding for more regular review and follow-up and draws attention to potentially reversible bleeding risk factors. The aim of this review article is to provide an overview of recent advances in the understanding and management of AF with a focus on stroke prevention.
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Affiliation(s)
- Farhan Shahid
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | - Eduard Shantsila
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Amin A. Role of hospitalists in the diagnosis of atrial fibrillation for the management of cryptogenic stroke patients. Hosp Pract (1995) 2016; 44:274-278. [PMID: 27817241 DOI: 10.1080/21548331.2016.1258292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Cryptogenic strokes are responsible for significant morbidity and mortality. Identifying the underlying cause of cryptogenic stroke is imperative for appropriate short and long-term management of these patients. In particular, detecting atrial fibrillation in cryptogenic stroke patients may shed insight into the cause of the index stroke, but is also important to identify an important cause of secondary stroke. There is accumulating evidence indicating that monitoring for durations beyond the guideline recommended 30 day-period results in greater atrial fibrillation yield. This article reviews current guidelines and practices for the diagnosis of cryptogenic stroke, as well as outpatient cardiac monitoring options available, and focuses on the role that hospitalists have to play in the care of these patients.
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Affiliation(s)
- Alpesh Amin
- a Department of Medicine , University of California Irvine , Orange , CA , USA
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66
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[Implantable loop recorder in atrial fibrillation and after catheter ablation]. Herzschrittmacherther Elektrophysiol 2016; 27:355-359. [PMID: 27832334 DOI: 10.1007/s00399-016-0471-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 08/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Implantable loop recorders (ILR) are an established diagnostic method for detection of cardiac arrhythmias including atrial fibrillation. OBJECTIVE The aim of this work is to provide an overview of available data and indications of ILR in atrial fibrillation, especially after catheter ablation, in order to illustrate practice-oriented recommendations. MATERIALS AND METHODS We conducted a selective PubMed literature search. RESULTS AND DISCUSSION ILR can record asymptomatic/rare atrial fibrillation episodes and prevent thromboembolic events by allowing timely initiation of oral anticoagulation. They can be used to assess therapeutic success after percutaneous or surgical ablation, if despite increased thromboembolic risk, no oral anticoagulation is desired. ILR equipped with remote monitoring function and special P wave detection algorithms may improve diagnostic confidence.
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67
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Korompoki E, Del Giudice A, Hillmann S, Malzahn U, Gladstone DJ, Heuschmann P, Veltkamp R. Cardiac monitoring for detection of atrial fibrillation after TIA: A systematic review and meta-analysis. Int J Stroke 2016; 12:33-45. [DOI: 10.1177/1747493016669885] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background and purpose The detection rate of atrial fibrillation has not been studied specifically in transient ischemic attack (TIA) patients although extrapolation from ischemic stroke may be inadequate. We conducted a systematic review and meta-analysis to determine the rate of newly diagnosed atrial fibrillation using different methods of ECG monitoring in TIA. Methods A comprehensive literature search was performed following a pre-specified protocol the PRISMA statement. Prospective observational studies and randomized controlled trials were considered that included TIA patients who underwent cardiac monitoring for >12 h. Primary outcome was frequency of detection of atrial fibrillation ≥30 s. Analyses of subgroups and of duration and type of monitoring were performed. Results Seventeen studies enrolling 1163 patients were included. The pooled atrial fibrillation detection rate for all methods was 4% (95% CI: 2–7%). Yield of monitoring was higher in selected (higher age, more extensive testing for arrhythmias before enrolment, or presumed cardioembolic/cryptogenic cause) than in unselected cohorts (7% vs 3%). Pooled mean atrial fibrillation detection rates rose with duration of monitoring: 4% (24 h), 5% (24 h to 7 days) and 6% (>7 days), respectively. Yield of non-invasive was significantly lower than that of invasive monitoring (4% vs. 11%). Significant heterogeneity was observed among studies (I2=60.61%). Conclusion This first meta-analysis of atrial fibrillation detection in TIA patients finds a lower atrial fibrillation detection rate in TIA than reported for IS and TIA cohorts in previous meta-analyses. Prospective studies are needed to determine actual prevalence of atrial fibrillation and optimal diagnostic procedure for atrial fibrillation detection in TIA.
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Affiliation(s)
- Eleni Korompoki
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - Angela Del Giudice
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - Steffi Hillmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Uwe Malzahn
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Clinical Trial Center, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - David J Gladstone
- Division of Neurology, Department of Medicine, University Toronto, Ontario, Canada
| | - Peter Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Clinical Trial Center, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
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68
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A Simple, Non-Invasive Score to Predict Paroxysmal Atrial Fibrillation. PLoS One 2016; 11:e0163621. [PMID: 27680490 PMCID: PMC5040399 DOI: 10.1371/journal.pone.0163621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 09/12/2016] [Indexed: 11/29/2022] Open
Abstract
Paroxysmal atrial fibrillation (pAF) is a major risk factor for stroke but remains often unobserved. To predict the presence of pAF, we developed model scores based on echocardiographic and other clinical parameters from routine cardiac assessment. The scores can be easily implemented to clinical practice and might improve the early detection of pAF. In total, 47 echocardiographic and other clinical parameters were collected from 1000 patients with sinus rhythm (SR; n = 728), pAF (n = 161) and cAF (n = 111). We developed logistic models for classifying between pAF and SR that were reduced to the most predictive parameters. To facilitate clinical implementation, linear scores were derived. To study the pathophysiological progression to cAF, we analogously developed models for cAF prediction. For classification between pAF and SR, amongst 12 selected model parameters, the most predictive variables were tissue Doppler imaging velocity during atrial contraction (TDI, A’), left atrial diameter, age and aortic root diameter. Models for classifying between pAF and SR or between cAF and SR showed areas under the ROC curves of 0.80 or 0.93, which resembles classifiers with high discriminative power. The novel risk scores were suitable to predict the presence of pAF based on variables readily available from routine cardiac assessment. Modelling helped to quantitatively characterize the pathophysiologic transition from SR via pAF to cAF. Applying the scores may improve the early detection of pAF and might be used as decision aid for initiating preventive interventions to reduce AF-associated complications.
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69
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Krieger DW. New insights into protecting the brain from the heart. FUTURE NEUROLOGY 2016. [DOI: 10.2217/fnl-2016-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Derk W Krieger
- Mediclinic City Hospital, Dubai Healthcare City, Dubai, UAE
- Comprehensive Stroke Center, USZ Zurich, Switzerland
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70
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La función de la aurícula izquierda está alterada en algunos pacientes con ictus criptogénico: potenciales implicaciones en su evaluación y tratamiento. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2015.11.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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71
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Anczykowski J, Willems S, Hoffmann BA, Meinertz T, Blankenberg S, Patten M. Early Detection of Symptomatic Paroxysmal Cardiac Arrhythmias by Trans-Telephonic ECG Monitoring: Impact on Diagnosis and Treatment of Atrial Fibrillation. J Cardiovasc Electrophysiol 2016; 27:1032-7. [PMID: 27257094 DOI: 10.1111/jce.13025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 05/11/2016] [Accepted: 05/16/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Diagnosis of infrequent cardiac arrhythmias (CA) is often unsuccessful using resting or Holter ECG. As early detection and treatment of CA, especially atrial fibrillation (AF), has implications on patients' treatment and outcome, we investigated, whether self-guided, trans-telephonic event-recorder monitoring (Tele-ECG) improves diagnosis and influences treatment options. METHODS Between 2009 and 2014, 790 patients (54 ± 18 years, 40% male; no history of CA: 582, known AF: 179, other CA: 29) presented with recurrent symptoms suggestive of CA and were screened by Tele-ECG (17.3 ± 26.9 days). A total of 11,775 ECGs were transmitted via a 24-hour telephone hotline including documentation of the respective symptoms. RESULTS In 73% of patients, CA was documented at the time of symptoms: sinus tachycardia 23%, premature ventricular beats 19%, AF 14%, supraventricular tachycardia 9%, sinus bradycardia 5%, sinus arrhythmia 2%, and AV block II 1%. The mean time until the first symptomatic episode occurred was 6.9 ± 15.3 days (median 2.5 days). The first documented arrhythmia occurred on average after 7.7 ± 14.1 days (median 3 days). In patients with AF (n = 110), 44% was newly diagnosed. According to the Tele-ECG diagnosis, AF ablation was performed in 27% of these patients, 7% electrical cardioversion, and in 30% antiarrhythmic therapy was initiated. In 65% of the patients with recurrence of known AF, (re-)ablation was performed or recommended and in 16% antiarrhythmic therapy was modified. CONCLUSIONS Tele-ECG monitoring is effective in the diagnosis of suspected symptomatic CA. A diagnosis can usually be achieved within 1 week and has implications on patients' care.
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Affiliation(s)
- Johanna Anczykowski
- Department of Clinical and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Stephan Willems
- Department of Cardiology - Electrophysiology, University Heart Center Hamburg, Hamburg, Germany
| | - Boris A Hoffmann
- Department of Cardiology - Electrophysiology, University Heart Center Hamburg, Hamburg, Germany
| | - Thomas Meinertz
- Department of Clinical and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Clinical and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Monica Patten
- Department of Clinical and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.
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Paroxysmal Atrial Fibrillation: Novel Strategies for Monitoring and Implications for Treatment in Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:52. [DOI: 10.1007/s11936-016-0475-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bridge F, Thijs V. How and When to Screen for Atrial Fibrillation after Stroke: Insights from Insertable Cardiac Monitoring Devices. J Stroke 2016; 18:121-8. [PMID: 27283276 PMCID: PMC4901953 DOI: 10.5853/jos.2016.00150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/24/2016] [Accepted: 04/25/2016] [Indexed: 01/16/2023] Open
Abstract
The introduction of insertable cardiac monitoring devices has dramatically altered our understanding of the role of intermittent atrial fibrillation in cryptogenic stroke. In this narrative review we discuss the incidence, timing and relationship between atrial fibrillation and cryptogenic stroke, how to select patients for monitoring and the value and limitations of different monitoring strategies. We also discuss the role of empirical anticoagulation, and atrial fibrillation burden as a means of tailoring anticoagulation in patients at high risk of bleeding.
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Affiliation(s)
- Francesca Bridge
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Vincent Thijs
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
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Brachmann J, Morillo CA, Sanna T, Di Lazzaro V, Diener HC, Bernstein RA, Rymer M, Ziegler PD, Liu S, Passman RS. Uncovering Atrial Fibrillation Beyond Short-Term Monitoring in Cryptogenic Stroke Patients: Three-Year Results From the Cryptogenic Stroke and Underlying Atrial Fibrillation Trial. Circ Arrhythm Electrophysiol 2016; 9:e003333. [PMID: 26763225 DOI: 10.1161/circep.115.003333] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) can be a cause of previously diagnosed cryptogenic stroke. However, AF can be paroxysmal and asymptomatic, thereby making detection with routine ECG methods difficult. Oral anticoagulation is highly effective in reducing recurrent stroke in patients with AF, but its initiation is dependent on the detection of AF. Cryptogenic Stroke and Underlying Atrial Fibrillation (CRYSTAL AF) is the first randomized study to report the detection of AF in cryptogenic stroke patients using continuous long-term monitoring via insertable cardiac monitors (ICM). METHODS AND RESULTS Patients with prior cryptogenic stroke were randomized to control (n=220) or ICM (n=221) and followed for ≤36 months. Cumulative AF detection rates in the ICM arm increased progressively during this period (3.7%, 8.9%, 12.4%, and 30.0% at 1, 6, 12, and 36 months, respectively), but remained low in the control arm (3.0% at 36 months). This resulted in oral anticoagulation prescription in 94.7% of ICM patients with AF detected at 6 months, 96.6% at 12 months, and 90.5% at 36 months. Among ICM patients with AF detected, the median time to AF detection was 8.4 months, 81.0% of first AF episodes were asymptomatic, and 94.9% had at least 1 day with >6 minutes of AF. CONCLUSIONS Three-year monitoring by ICM in cryptogenic stroke patients demonstrated a significantly higher AF detection rate compared with routine care. Given the frequency of asymptomatic first episodes and the long median time to detection, these findings highlight the limitations of using traditional AF detection methods. The majority of patients with AF were prescribed oral anticoagulation therapy. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov; Unique identifier: NCT00924638.
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Affiliation(s)
- Johannes Brachmann
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.).
| | - Carlos A Morillo
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Tommaso Sanna
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Vincenzo Di Lazzaro
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Hans-Christoph Diener
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Richard A Bernstein
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Marylin Rymer
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Paul D Ziegler
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Shufeng Liu
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
| | - Rod S Passman
- From the Department of Cardiology, Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany (J.B.); Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); Department of Cardiac Intensive Care, Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (T.S.); Department of Neurology, Institute of Neurology, Università Campus Bio-Medico, Rome, Italy (V.D.L.); Department of Neurology & Stroke Center, University Hospital Essen, Essen, Germany (H.-C.D.); Davee Department of Neurology (R.A.B.) and Bluhm Cardiovascular Institute (R.S.P.), Northwestern University Feinberg School of Medicine, Chicago, IL; University of Kansas Medical Center, Kansas City, KS (M.R.); Departments of Diagnostics and Monitoring Research (P.D.Z.) and Statistics (S.L.), Medtronic, Mounds View, MN; and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL (R.S.P.)
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Albers GW, Bernstein RA, Brachmann J, Camm J, Easton JD, Fromm P, Goto S, Granger CB, Hohnloser SH, Hylek E, Jaffer AK, Krieger DW, Passman R, Pines JM, Reed SD, Rothwell PM, Kowey PR. Heart Rhythm Monitoring Strategies for Cryptogenic Stroke: 2015 Diagnostics and Monitoring Stroke Focus Group Report. J Am Heart Assoc 2016; 5:e002944. [PMID: 27068633 PMCID: PMC4943268 DOI: 10.1161/jaha.115.002944] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA
| | - Richard A Bernstein
- Davee Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Johannes Brachmann
- Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany
| | - John Camm
- Cardiovascular and Cell Sciences Research Institute, St. George's University of London and Imperial College, London, UK
| | - J Donald Easton
- Department of Neurology, University of California San Francisco, Sandler Neurosciences Center, San Francisco, CA
| | - Peter Fromm
- Center for Cardiovascular Health, South Nassau Communities Hospital, Oceanside, NY
| | - Shinya Goto
- Department of Medicine, Tokai University School of Medicine, Isehara, Japan
| | | | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J.W. Goethe University, Frankfurt, Germany
| | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Amir K Jaffer
- Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Derk W Krieger
- Faculty of Health and Medical Science, University of Copenhagen, Denmark German Neuroscience Center, Dubai Healthcare City, Dubai, UAE
| | - Rod Passman
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jesse M Pines
- Office for Clinical Practice Innovation, George Washington University, Washington, DC
| | - Shelby D Reed
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Peter M Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Peter R Kowey
- Division of Cardiovascular Diseases, Lankenau Heart Institute, Wynnewood, PA Department of Medicine, Jefferson Medical College, Philadelphia, PA
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Sanchis L, Montserrat S, Obach V, Cervera Á, Chamorro Á, Vidal B, Mas-Stachurska A, Bijnens B, Sitges M. Left Atrial Function Is Impaired in Some Patients With Stroke of Undetermined Etiology: Potential Implications for Evaluation and Therapy. ACTA ACUST UNITED AC 2016; 69:650-6. [PMID: 26949013 DOI: 10.1016/j.rec.2015.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES Stroke etiology remains undetermined in up to 30% of cases. Paroxysmal atrial fibrillation is found in 20% to 28% of patients with stroke initially classified as being of undetermined etiology. The aim of our study was to analyze left atrial function in ischemic stroke patients to identify patterns associated with cardioembolic etiology and to determine whether the patterns identified can be found in individuals initially classified as having a stroke of undetermined etiology. METHODS We studied a cohort of in-hospital ischemic stroke patients referred for transthoracic echocardiography. Treating neurologists determined stroke etiology based on the TOAST classification. Left atrial contractile function was assessed using 2-dimensional echocardiography to determine their ejection fraction and speckle tracking to measure left atrial strain rate: a-wave. Left atrial function was compared between stroke etiology subgroups and healthy controls. RESULTS Ninety-seven patients (aged 67±15 years) with ischemic stroke (16.5% large-artery atherosclerosis, 15.5% small-vessel occlusion, 11.3% cardioembolic, 5.1% other determined etiology, 51.1% undetermined etiology) and 10 healthy volunteers (aged 63±7 years) were included. Left atrial ejection fraction was significantly decreased only in patients with stroke of cardioembolic and undetermined etiology compared with the control group (31.5±17.2%, 40.2±17.1%, and 59.1±8.4%, respectively; P=.004). The left atrial strain rate was significantly lower in patients with stroke caused by cardioembolic or undetermined etiology, or large-artery atherosclerosis compared with controls (-0.86±0.49, -1.31±0.56, -1.5±0.47, -2.37±1.18, respectively; P<.001). CONCLUSIONS Patients with stroke of undetermined etiology with left atrial function (ejection fraction and strain) similar to that of cardioembolic stroke patients may be misclassified and could potentially benefit from prolonged electrocardiography monitoring. Left atrial function analysis (ejection fraction and strain) might help to identify potential cardioembolic sources in patients with stroke of undetermined etiology.
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Affiliation(s)
- Laura Sanchis
- Departamento de Cardiología, Hospital Clínic, IDIBAPS, Universidad de Barcelona, Spain.
| | - Silvia Montserrat
- Departamento de Cardiología, Hospital Clínic, IDIBAPS, Universidad de Barcelona, Spain
| | - Víctor Obach
- Departamento de Neurología, Hospital Clínic, Barcelona, Spain
| | - Álvaro Cervera
- Departamento de Neurología, Hospital Clínic, Barcelona, Spain
| | - Ángel Chamorro
- Departamento de Neurología, Hospital Clínic, Barcelona, Spain
| | - Bàrbara Vidal
- Departamento de Cardiología, Hospital Clínic, IDIBAPS, Universidad de Barcelona, Spain
| | | | - Bart Bijnens
- ICREA-Universidad Pompeu Fabra, Barcelona, Spain
| | - Marta Sitges
- Departamento de Cardiología, Hospital Clínic, IDIBAPS, Universidad de Barcelona, Spain
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Miller DJ, Shah K, Modi S, Mahajan A, Zahoor S, Affan M. The Evolution and Application of Cardiac Monitoring for Occult Atrial Fibrillation in Cryptogenic Stroke and TIA. Curr Treat Options Neurol 2016; 18:17. [PMID: 26923607 DOI: 10.1007/s11940-016-0400-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OPINION STATEMENT The evaluation of the stroke and transient ischemic attack (TIA) patient has been historically predominated by the initial evaluation in the hospital setting. As the etiology of stroke has eluded us in approximately one third of all acute events, the medical community has been eager to seek the answer to this mystery. In recent years, we have seen an explosion of innovations and trends allowing for a more detailed post stroke assessment strategy aimed at the identification of occult atrial fibrillation as the etiologic cause for the cryptogenic event. This has been achieved through the evolution and aggressive application and study of prolonged and advanced cardiac monitoring. This review is aimed to clarify and elucidate the standard and novel cardiac monitoring methods that have become available for use by the medical community and expected in the higher level care of cryptogenic stroke and TIA patients. These cardiac monitoring methods and devices are as heterogeneous as our patient population and have their own advantages and disadvantages. Many factors may be taken into consideration in choosing the appropriate cardiac monitoring method and are highlighted for consideration in this review. With a judicious approach to investigating the cryptogenic stroke population, and applying a wealth of novel treatment options, we may move forward into a new era of stroke prevention.
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Affiliation(s)
- Daniel J Miller
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Kavit Shah
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Sumul Modi
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Abhimanyu Mahajan
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Salman Zahoor
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Muhammad Affan
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
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78
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Olsen FJ, Biering-Sørensen T, Krieger DW. An update on insertable cardiac monitors: examining the latest clinical evidence and technology for arrhythmia management. Future Cardiol 2016; 11:333-46. [PMID: 26021639 DOI: 10.2217/fca.15.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Continuous cardiac rhythm monitoring has undergone compelling progress over the past decades. Cardiac monitoring has emerged from 12-lead electrocardiograms being performed at the discretion of the treating physician to in-hospital telemetry, Holter monitoring, prolonged external event monitoring and most recently toward insertable device monitoring for several years. Significant advantages and disadvantages pertaining to these monitoring options will be addressed in this review. Insertable cardiac monitors have several advantages over external monitoring techniques and may signify a clinical turning point in the field of arrhythmia management. However, their role in the detection of paroxysmal atrial fibrillation after cryptogenic strokes has yet to evolve. This will be the main focus of this review. Issues surrounding patient selection, clinical relevance and determination of cost-effectiveness for prolonged cardiac monitoring require further studies. Furthermore, insertable cardiac monitoring has not only the potential to augment diagnostic capabilities but also to improve the management of paroxysmal atrial fibrillation.
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Affiliation(s)
- Flemming J Olsen
- 1Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- 1Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Derk W Krieger
- 4Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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79
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Burkowitz J, Merzenich C, Grassme K, Brüggenjürgen B. Insertable cardiac monitors in the diagnosis of syncope and the detection of atrial fibrillation: A systematic review and meta-analysis. Eur J Prev Cardiol 2016; 23:1261-72. [PMID: 26864396 DOI: 10.1177/2047487316632628] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 01/25/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Insertable or implantable cardiac monitors (ICMs) continuously monitor the heart rhythm and record irregularities over 3 years, enabling the diagnosis of infrequent rhythm abnormalities associated with syncope and stroke. The enhanced recognition capabilities of recent ICM models are able to accurately detect atrial fibrillation (AF) and have led to new applications of ICMs for the detection and monitoring of AF. METHODS AND RESULTS Based on a systematic literature search, two indications were identified for ICMs for which considerable evidence, including randomized studies, exists: diagnosing the underlying cardiac cause of unexplained recurrent syncope and detecting AF in patients after cryptogenic stroke (CS). Three randomized controlled trials (RCTs) were identified that compared the effectiveness of ICMs in diagnosing patients with unexplained syncope (n = 556) to standard of care. A meta-analysis was conducted in order to generate an overall effect size and confidence interval of the diagnostic yield of ICMs versus conventional monitoring. In the indication CS, one RCT and five observational studies were included in order to assess the performance of ICMs in diagnosing patients with AF (n = 1129). Based on these studies, there is strong evidence that ICMs provide a higher diagnostic yield for detecting arrhythmias in patients with unexplained syncope and for detection of AF in patients after CS compared to conventional monitoring. CONCLUSIONS Prolonged monitoring with ICMs is an effective tool for diagnosing the underlying cardiac cause of unexplained syncope and for detecting AF in patients with CS. In all RCTs, ICMs have a superior diagnostic yield compared to conventional monitoring.
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Affiliation(s)
- Jörg Burkowitz
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Carina Merzenich
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Kathrin Grassme
- Boston Healthcare Associates International GmbH, Berlin, Germany
| | - Bernd Brüggenjürgen
- Charité University Medicine Berlin, Institute for Social Medicine, Epidemiology and Health Economy, Berlin, Germany
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80
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Lau CP, Siu CW, Yiu KH, Lee KLF, Chan YH, Tse HF. Subclinical atrial fibrillation and stroke: insights from continuous monitoring by implanted cardiac electronic devices. Europace 2016; 17 Suppl 2:ii40-6. [DOI: 10.1093/europace/euv235] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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81
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Homma S, Messé SR, Rundek T, Sun YP, Franke J, Davidson K, Sievert H, Sacco RL, Di Tullio MR. Patent foramen ovale. Nat Rev Dis Primers 2016; 2:15086. [PMID: 27188965 DOI: 10.1038/nrdp.2015.86] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Patent foramen ovale (PFO) is the most common congenital heart abnormality of fetal origin and is present in approximately ∼25% of the worldwide adult population. PFO is the consequence of failed closure of the foramen ovale, a normal structure that exists in the fetus to direct blood flow directly from the right to the left atrium, bypassing the pulmonary circulation. PFO has historically been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi that shunt through the PFO directly to the left atrium. However, several studies have failed to show an increased risk of stroke in asymptomatic patients with a PFO, and the risk of stroke recurrence is low in patients who have had a stroke that may be attributed to a PFO. With the advent of transoesophageal and transthoracic echocardiography, as well as transcranial Doppler, a PFO can be routinely detected in clinical practice. Medical treatment with either antiplatelet or anticoagulation therapy is recommended. At the current time, closure of the PFO by percutaneous interventional techniques does not appear to reduce the risk of stroke compared to conventional medical treatment, as shown by three large clinical trials. Considerable controversy remains regarding the optimal treatment strategy for patients with both cryptogenic stroke and PFO. This Primer discusses the epidemiology, mechanisms, pathophysiology, diagnosis, screening, management and effects on quality of life of PFO.
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Affiliation(s)
- Shunichi Homma
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Yee-Ping Sun
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Karina Davidson
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
| | | | - Ralph L Sacco
- Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Marco R Di Tullio
- Department of Medicine, Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York 10032, USA
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82
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Diamantopoulos A, Sawyer LM, Lip GYH, Witte KK, Reynolds MR, Fauchier L, Thijs V, Brown B, Quiroz Angulo ME, Diener HC. Cost-effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke. Int J Stroke 2016; 11:302-12. [DOI: 10.1177/1747493015620803] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 10/15/2015] [Indexed: 11/16/2022]
Abstract
Background and aims Documentation of atrial fibrillation is required to initiate oral anticoagulation therapy for recurrent stroke prevention. Atrial fibrillation often goes undetected with traditional electrocardiogram monitoring techniques. We evaluated whether atrial fibrillation detection using continuous long-term monitoring with an insertable cardiac monitor is cost-effective for preventing recurrent stroke in patients with cryptogenic stroke, in comparison to the standard of care. Methods A lifetime Markov model was developed to estimate the cost-effectiveness of insertable cardiac monitors from a UK National Health Service perspective using data from the randomized CRYSTAL-AF trial and other published literature. We also conducted scenario analyses (CHADS2 score) and probabilistic sensitivity analyses. All costs and benefits were discounted at 3.5%. Results Monitoring cryptogenic stroke patients with an insertable cardiac monitor was associated with fewer recurrent strokes and increased quality-adjusted life years compared to the standard of care (7.37 vs 7.22). Stroke-related costs were reduced in insertable cardiac monitor patients, but overall costs remained higher than the standard of care (£19,631 vs £17,045). The incremental cost-effectiveness ratio was £17,175 per quality-adjusted life years gained, compared to standard of care in the base-case scenario, which is below established quality-adjusted life years willingness-to-pay thresholds. When warfarin replaced non-vitamin-K oral anticoagulants as the main anticoagulation therapy, the incremental cost-effectiveness ratio was £13,296 per quality-adjusted life years gained. Conclusion Insertable cardiac monitors are a cost-effective diagnostic tool for the prevention of recurrent stroke in patients with cryptogenic stroke. The cost-effectiveness results have relevance for the UK and across value-based healthcare systems that assess costs relative to outcomes.
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Affiliation(s)
| | | | - Gregory YH Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Klaus K Witte
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Matthew R Reynolds
- Economics and Quality of Life Research, Harvard Clinical Research Institute, Boston, MA, USA
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
| | - Vincent Thijs
- Department of Neurology, Austin Health and Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
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83
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Skaarup KG, Christensen H, Høst N, Mahmoud MM, Ovesen C, Olsen FJ, Biering-Sørensen T. Diagnosing Paroxysmal Atrial Fibrillation in Patients With Ischemic Strokes and Transient Ischemic Attacks Using Echocardiographic Measurements of Left Atrium Function. Am J Cardiol 2016; 117:91-9. [PMID: 26525212 DOI: 10.1016/j.amjcard.2015.10.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/09/2015] [Accepted: 10/09/2015] [Indexed: 11/17/2022]
Abstract
Twenty-five to 35 percentage of stroke cases are cryptogenic, and it has been demonstrated that paroxysmal atrial fibrillation (AF) is the causal agent in up to 25% of these incidents. The purpose of this study was to investigate if left atrial (LA) parameters have value for diagnosing paroxysmal AF in patients with ischemic stroke (IS) and transient ischemic attack (TIA). We retrospectively analyzed 219 patients who after acute IS or TIA underwent a transthoracic echocardiographic examination. Patients were designated as patients with paroxysmal AF if they had one or more reported incidents of AF before or after their echocardiographic examination. Patients in the paroxysmal AF group were significantly older and had higher CHA2DS2-VASc score than patients without paroxysmal AF (p <0.05 for both). None of the conventional echocardiographic parameters were significantly associated with paroxysmal AF. However, the atrial measurements evaluating LA function (min LA volume and LA emptying fraction) were significantly different (LA emptying fraction: 45% ± 10% vs 50% ± 10%, p = 0.004; minimal LA volume: 30.2 ml ± 17.3 ml vs 24 ml ± 10 ml, p = 0.035 in patients with paroxysmal AF, even after adjustment for age, gender, CHA2DS2-VASc score, and stroke severity [p <0.05 for both]). By combining the cut-off values of age, LA emptying fraction, and minimal LA volume the diagnostic accuracy of paroxysmal AF was improved, resulting in a sensitivity of 95% and negative predictive value of 97%. In conclusion, in patients with IS and TIA, LA function measurements (minimal LA volume and LA emptying fraction) are independently associated with paroxysmal AF and may improve risk stratification for paroxysmal AF presence after IS or TIA.
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Affiliation(s)
- Kristoffer Grundtvig Skaarup
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Denmark; Department of Cardiology, Gentofte Hospital, University of Copenhagen, Denmark.
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Nis Høst
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Denmark
| | - Masti Mahdy Mahmoud
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Denmark
| | - Christian Ovesen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Denmark
| | | | - Tor Biering-Sørensen
- Department of Cardiology, Gentofte Hospital, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark
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84
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Affiliation(s)
- A H V Schapira
- Department of Clinical Neurosciences, UCL Institute of Neurology, London, UK.
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85
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Zhang C, Kasner SE. Paroxysmal Atrial Fibrillation in Cryptogenic Stroke: an Overlooked Explanation? Curr Atheroscler Rep 2015; 17:66. [PMID: 26486510 DOI: 10.1007/s11883-015-0547-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Approximately one third of ischemic strokes are labeled cryptogenic because the etiology is unknown despite a thorough evaluation. Paroxysmal atrial fibrillation carries the same risk of ischemic stroke as persistent atrial fibrillation and has increasingly gained attention as a potential source of cryptogenic stroke. Recent trials utilizing long-term cardiac monitoring devices have demonstrated high rates of previously undetected paroxysmal atrial fibrillation in patients with cryptogenic stroke. Newly detected atrial fibrillation has subsequently changed treatment and increased the use of oral anticoagulation in these studies. Other trials have shown an increased risk of stroke and thromboembolism in patients with device-detected subclinical tachyarrhythmias. Together, these studies suggest an important relationship between episodes of paroxysmal atrial fibrillation and the risk of cryptogenic stroke, but further investigations are needed to guide diagnostic and therapeutic decisions.
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Affiliation(s)
- Cen Zhang
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Scott E Kasner
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA.
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86
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Abstract
Identifying occult paroxysmal atrial fibrillation as the etiology of cryptogenic stroke has been a top research priority in the past decade. This is because prompt initiation of anticoagulation has significantly decreased subsequent stroke risk. Available evidence suggests that prolonged cardiac monitoring after stroke increases the likelihood of detecting atrial fibrillation. However, further research is required to fill in the gaps in regard to the optimal period of monitoring, candidates for monitoring, etc. Here, we review the current evidence supporting the use of prolonged monitoring for cryptogenic stroke patients and discuss the directions of future research.
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87
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AFZAL MUHAMMADR, GUNDA SAMPATH, WAHEED SALMAN, SEHAR NANDHINI, MAYBROOK RYANJ, DAWN BUDDHADEB, LAKKIREDDY DHANUNJAYA. Role of Outpatient Cardiac Rhythm Monitoring in Cryptogenic Stroke: A Systematic Review and Meta-Analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1236-45. [DOI: 10.1111/pace.12688] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/23/2015] [Accepted: 06/28/2015] [Indexed: 11/28/2022]
Affiliation(s)
- MUHAMMAD R. AFZAL
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - SAMPATH GUNDA
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - SALMAN WAHEED
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - NANDHINI SEHAR
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - RYAN J. MAYBROOK
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - BUDDHADEB DAWN
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - DHANUNJAYA LAKKIREDDY
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
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88
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Hernández Olmedo M, Suárez Fernández C. Avances en el tratamiento anticoagulante de la fibrilación auricular. Med Clin (Barc) 2015; 145:124-30. [DOI: 10.1016/j.medcli.2014.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/07/2014] [Accepted: 07/07/2014] [Indexed: 10/24/2022]
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89
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Banchs JE, Scher DL. Emerging role of digital technology and remote monitoring in the care of cardiac patients. Med Clin North Am 2015; 99:877-96. [PMID: 26042888 DOI: 10.1016/j.mcna.2015.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Current available mobile health technologies make possible earlier diagnosis and long-term monitoring of patients with cardiovascular diseases. Remote monitoring of patients with implantable devices and chronic diseases has resulted in better outcomes reducing health care costs and hospital admissions. New care models, which shift point of care to the outpatient setting and the patient's home, necessitate innovations in technology.
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Affiliation(s)
- Javier E Banchs
- Department of Medicine, Division of Cardiology, Section of Cardiac Electrophysiology and Pacing, 2401 South 31st Street, Temple, TX 76508, USA.
| | - David Lee Scher
- Department of Medicine, Division of Cardiology, Penn State Hershey Heart & Vascular Institute, 500 University Drive, H047, Hershey, PA 17033, USA
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90
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Excessive Atrial Ectopy and Short Atrial Runs Increase the Risk of Stroke Beyond Incident Atrial Fibrillation. J Am Coll Cardiol 2015; 66:232-241. [DOI: 10.1016/j.jacc.2015.05.018] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 05/06/2015] [Accepted: 05/11/2015] [Indexed: 11/22/2022]
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91
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Akinboboye O. Use of oral anticoagulants in African-American and Caucasian patients with atrial fibrillation: is there a treatment disparity? J Multidiscip Healthc 2015; 8:217-28. [PMID: 26056467 PMCID: PMC4445875 DOI: 10.2147/jmdh.s74529] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Atrial fibrillation (AF) is a very common cardiac arrhythmia, and its prevalence is increasing along with aging in the developed world. This review discusses racial differences in the epidemiology and treatment of AF between African-American and Caucasian patients. Additionally, the effect of race on warfarin and novel oral anticoagulant use is discussed, as well as the role that physicians and patients play in achieving optimal treatment outcomes. Despite having a lower prevalence of AF compared with Caucasians, African-Americans suffer disproportionately from stroke and its sequelae. The possible reasons for this paradox include poorer access to health care, lower health literacy, and a higher prevalence of other stroke-risk factors among African-Americans. Consequently, it is important for providers to evaluate the effects of race, health literacy, access to health care, and cultural barriers on the use of anticoagulation in the management of AF. Warfarin-dose requirements vary across racial groups, with African-American patients requiring a higher dose than Caucasians to maintain a therapeutic international normalized ratio; the novel oral anticoagulants (dabigatran, rivaroxaban, and apixaban) seem to differ in this regard, although data are currently limited. Minority racial groups are not proportionally represented in either real-world studies or clinical trials, but as more information becomes available and other social issues are addressed, the treatment disparities between African-American and Caucasian patients should decrease.
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92
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Ali AN, Howe J, Abdel-Hafiz A. Cost of acute stroke care for patients with atrial fibrillation compared with those in sinus rhythm. PHARMACOECONOMICS 2015; 33:511-520. [PMID: 25693879 DOI: 10.1007/s40273-015-0263-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a major risk factor for stroke. Cost-effectiveness studies of anticoagulants for stroke prevention in AF rarely utilise AF-stroke-specific cost data in their analyses, as data are limited. Data that exist do not account for AF found on prolonged cardiac monitoring after stroke, further underestimating the clinical and economic burden of AF-stroke. OBJECTIVE Our objective was to investigate differences in direct medical costs of acute stroke care among patients with and without AF. METHODS Data were prospectively collected from 213 consecutive patients with confirmed stroke (196 ischaemic [IS], 17 intracranial haemorrhage [ICH]), admitted to a UK district general hospital between November 2011 and October 2012. Sociodemographic, clinical and cardiac monitoring characteristics were recorded, and resource use was calculated using a 'bottom-up' approach. Univariate and multivariate stepwise regressions were performed to identify predictors of direct cost. RESULTS Among patients with IS, 73 had AF (37%). These patients were older, experienced greater stroke severity, lengths of hospitalisation, inpatient mortality and discharge to institutionalised care than those without AF. Mean acute care costs for the year 2012 were £6,978 (standard deviation [SD] 6,769, range 510-36,952). Mean (SD) costs were significantly higher for patients with AF than for those without (£9,083 [7,381] vs. £5,729 [6,071], p = <0.001). AF independently predicted acute care cost along with history of heart failure and stroke severity. The adjusted independent effect of having AF on costs was an additional £2,173 (95% confidence interval 91-4,254; p = 0.041). Costs for patients with an ICH did not differ according to cardiac rhythm. CONCLUSION Direct medical costs of acute stroke care for patients with AF may be 50% greater than for patients without. Economic studies should take this into account to ensure the benefits of anticoagulants are not underestimated.
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Affiliation(s)
- Ali N Ali
- Stroke Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Glossop Road, Sheffield, S10 2JF, UK,
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93
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Andrade JG, Field T, Khairy P. Detection of occult atrial fibrillation in patients with embolic stroke of uncertain source: a work in progress. Front Physiol 2015; 6:100. [PMID: 25883570 PMCID: PMC4381503 DOI: 10.3389/fphys.2015.00100] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/12/2015] [Indexed: 02/02/2023] Open
Abstract
Atrial fibrillation accounts for a substantial proportion of ischemic strokes of known etiology and may be responsible for an additional subset of the 25–40% of strokes of unknown cause (so-called cryptogenic). Oral anticoagulation is significantly more effective than antiplatelet therapy in the secondary prevention of atrial fibrillation-related strokes, providing justification for developing more sensitive approaches to detecting occult paroxysms of atrial fibrillation. In this article, we summarize the current state of knowledge regarding the value of in-hospital and out-patient monitoring for detecting atrial fibrillation in the context of cryptogenic stroke. We review the evidence for and against screening with standard Holter monitors, external loop recorders, the newer real-time continuous attended cardiac monitoring systems, cardiac implantable electronic devices, and insertable loop recorders. We review key questions regarding prolonged cardiac arrhythmia monitoring, including the relationship between duration of the atrial fibrillation episode and risk of thromboembolism, frequency of monitoring and its impact on the diagnostic yield in detecting occult or subclinical atrial fibrillation, and the temporal proximity of device-detected atrial fibrillation to stroke events. We conclude by proposing avenues for further research.
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Affiliation(s)
- Jason G Andrade
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal Montreal, QC, Canada ; Department of Medicine, Division of Cardiology, University of British Columbia Vancouver, BC, Canada
| | - Thalia Field
- Department of Medicine, Division of Neurology, University of British Columbia Vancouver, BC, Canada
| | - Paul Khairy
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal Montreal, QC, Canada
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94
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Sposato LA, Cipriano LE, Saposnik G, Vargas ER, Riccio PM, Hachinski V. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2015; 14:377-87. [DOI: 10.1016/s1474-4422(15)70027-x] [Citation(s) in RCA: 387] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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95
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PérezRodon J, FranciscoPascual J, RivasGándara N, RocaLuque I, Bellera N, MoyaMitjans À. Cryptogenic Stroke And Role Of Loop Recorder. J Atr Fibrillation 2014; 7:1178. [PMID: 27957141 DOI: 10.4022/jafib.1178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/12/2014] [Accepted: 12/21/2014] [Indexed: 12/29/2022]
Abstract
Ischemic stroke is an important cause of morbidity and mortality when untreated. Identifying atrial fibrillation is important because atrial fibrillation ischemic related strokes are associated with an increased risk of disability and death compared with strokes of other etiologies and tend to recur without anticoagulation. However, atrial fibrillation detection can be difficult when it is asymptomatic and paroxistic and may be the underlying cause of some cryptogenic strokes or strokes of unknown origin. In this review, the different methods of cardiac monitoring to detect atrial fibrillation in patients with cryptogenic stroke are summarized, with a focus on loop recorder monitoring.
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Affiliation(s)
- Jordi PérezRodon
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Jaume FranciscoPascual
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Nuria RivasGándara
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Ivo RocaLuque
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Neus Bellera
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Àngel MoyaMitjans
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
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Abstract
BACKGROUND Stroke without an identifiable cause is frightening to patients and their families and is frustrating for the caring physician. Approximately 30% of patients with cardiac implanted electronic devices have some evidence of atrial fibrillation (AF), and much of it is silent: asymptomatic, and previously unrecognized. OBJECTIVE The purpose of this review is to examine "silent AF" as a potential cause of cryptogenic stroke. METHODS/RESULTS We begin by reviewing most of the published literature on screening for AF with different monitoring technologies in the setting of cryptogenic stroke. We present the results of 2 recent large randomized trials, CRYSTAL AF and EMBRACE, which compare standard of care monitoring in cryptogenic stroke patients to invasive and noninvasive monitoring strategies, respectively. Finally, we review the relationship of silent AF to stroke in the cardiac implanted electronic device population. Patient selection, duration of monitoring, sensitivity and specificity of monitoring technology, patient compliance, and several other factors affect the yield of AF detection during monitoring. CONCLUSION Data suggest that silent AF is identified in approximately 30% of cryptogenic stroke patients and has important therapeutic implications. Oral anticoagulation likely should be prescribed when silent AF is detected.
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Affiliation(s)
- Taya V Glotzer
- Hackensack University Medical Center, Hackensack, New Jersey,.
| | - Paul D Ziegler
- Cardiac Rhythm Disease Management Division, Medtronic Inc, Mounds View, Minnesota
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