Effect of Implantable vs Prolonged External Electrocardiographic Monitoring on Atrial Fibrillation Detection in Patients With Ischemic Stroke: The PER DIEM Randomized Clinical Trial

Effect of implantable loop recorder-based continuous rhythm monitoring on incident atrial fibrillation and stroke: An updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

In patients with a history of stroke or those at high risk for developing stroke, a continuous rhythm monitoring strategy using an implantable loop recorder (ILR) is often performed to screen for atrial fibrillation (AF).

OBJECTIVES

The purpose of this study was to perform a systematic review (MEDLINE and EMBASE) including randomized controlled trials comparing ILR-based continuous rhythm monitoring vs usual care in patients with a history of stroke or patients at high risk for developing stroke.

METHODS

A meta-analysis was performed, and aggregate risk ratio (RR) and risk difference (RD) with 95% confidence interval (CI) were calculated.

RESULTS

Four randomized controlled trials with 7237 patients (ILR 2114, non-ILR 5123) were included. ILR vs non-ILR was associated with increased detection of incident AF (RR 3.88; 95% CI 2.23-6.75; P <.00001; number needed to treat [NNT] = 7.7; I2 = 61%), increased appropriate initiation of anticoagulation (RR 2.29; 95% CI 2.07-2.55; P <.00001; NNT = 6.7; I2 = 0), and a 25% lower risk of developing stroke (RR 0.75; 95% CI 0.59-0.95]; P = .02; NNT = 100; I2 = 0%). In patients with history of stroke there was no difference in the risk of developing incident stroke (RR 0.83; 95% CI 0.61-1.14]; P = .25; I2 = 0%).

CONCLUSION

Our meta-analysis showed that screening for AF with ILR is associated with increased detection of AF and increased initiation of appropriate anticoagulation therapy in patients with a history of stroke or those with risk factors for stroke. The benefit of stroke risk reduction with ILR remains unclear, and future studies focused on the inclusion of patients without a history of stroke are needed to elucidate this uncertainty.

Identifying the optimal time period for detection of atrial fibrillation after ischaemic stroke and TIA: An updated systematic review and meta-analysis of randomized control trials

BACKGROUND

Atrial fibrillation (AF) is a major risk factor for ischaemic stroke (IS) and transient ischaemic attack (TIA). The timely detection of first-diagnosed or "new" AF (nAF) would prompt a switch from antiplatelets to anticoagulation to reduce the risk of stroke recurrence; however, the optimal timing and duration of rhythm monitoring to detect nAF remains unclear.

AIMS

We searched MEDLINE, PubMed, Cochrane database, and Google Scholar to undertake a systematic review and meta-analysis of randomized controlled trials (RCT) between 2012 and 2023 investigating nAF detection after IS and TIA. Outcome measures were overall detection of nAF (control; (usual care) compared to intervention; (continuous cardiac monitoring >72 h)) and the time period in which nAF detection is highest (0-14 days, 15-90 days, 91-180 days, or 181-365 days). A random-effects model with generic inverse variance weights was used to pool the most adjusted effect measure from each trial.

SUMMARY OF REVIEW

A total of eight RCTs investigated rhythm monitoring after IS, totaling 5820 patients. The meta-analysis of the studies suggested that continuous cardiac monitoring was associated with a pooled odds ratio of 3.81 (95% CI 2.14 to 6.77), compared to usual care (control), for nAF detection. In the time period analysis, the odds ratio for nAF detection at 0-14 days, 15-90 days, 91-180 days, 181-365 days were 1.79 (1.24-2.58); 2.01 (0.63-6.37); 0.98 (0.16-5.90); and 2.92 (1.30-6.56), respectively.

CONCLUSION

There is an almost fourfold increase in nAF detection with continuous cardiac monitoring, compared to usual care. The results also demonstrate two statistically significant time periods in nAF detection; at 0-14 days and 6-12 months following monitoring commencement. These data support the utilization of different monitoring methods to cover both time periods and a minimum of 1 year of monitoring to maximize nAF detection in patients after IS and TIA.

Comparing the outcomes and costs of cardiac monitoring with implantable loop recorders and mobile cardiac outpatient telemetry following stroke using real-world evidence

Aim: Patients with ischemic stroke (IS) commonly undergo monitoring to identify atrial fibrillation with mobile cardiac outpatient telemetry (MCOT) or implantable loop recorders (ILRs). The authors compared readmission, healthcare cost and survival in patients monitored post-stroke with either MCOT or ILR. Materials & methods: The authors used claims data from Optum's de-identified Clinformatics® Data Mart Database to identify patients with IS hospitalized from January 2017 to December 2020 who were prescribed ambulatory cardiac monitoring via MCOT or ILR. They compared the costs associated with the initial inpatient visit as well as the rate and causes of readmission, survival and healthcare costs over the following 18 months. Datasets were balanced using patient baseline and hospitalization characteristics. Multivariable generalized linear gamma regression was used for cost comparisons. Cox proportional hazard regression was used for survival and readmission analysis. Sub-cohorts were analyzed based on the severity of the index IS. Results: In 2244 patients, readmissions were significantly lower in the MCOT monitored group (30.2%) compared with the ILR group (35.4%) (hazard ratio [HR] 1.23; 95% CI: 1.04-1.46). Average cost over 18 months starting with the index IS was $27,429 (USD) lower in the MCOT group (95% CI: $22,353-$32,633). Survival difference bordered on statistical significance and trended to lower mortality in MCOT (8.9%) versus ILR (11.3%) (HR 1.30; 95% CI: 1:00-1.69), led by significance in patients with complications or comorbidities with the index event (MCOT 7.5%, ILR 11.5%; HR 1.62; 95% CI: 1.11-2.36). Conclusion: The use of MCOT versus ILR as the primary monitor following IS was associated with significant decreases in readmission, lower costs for the initial IS and total care over the next 18 months, significantly lower mortality for patients with complications and comorbidities at the index stroke, and a trend toward improved survival across all patients.

Cardioembolic Stroke: Past Advancements, Current Challenges, and Future Directions

Cardioembolic stroke accounts for over 20% of ischemic strokes and is associated with worse outcomes than other types of strokes. Atrial fibrillation (AF) is the most common risk factor for cardioembolic stroke. In this narrative review, we present an update about cardioembolic stroke mainly related to AF and atrial cardiopathy. Direct oral anticoagulants (DOACs) have revolutionized stroke prevention in patients with AF; however, their efficacy in preventing recurrent embolic stroke of unknown source remains uncertain. Various cardiac monitoring methods are used to detect AF, which is crucial for preventing stroke recurrence. DOACs are preferred over warfarin for AF-related stroke prevention; however, the timing of initiation after acute ischemic stroke is debated. Resuming anticoagulation after intracerebral hemorrhage in AF patients requires careful assessment of the risks. While catheter ablation may reduce the incidence of cardiovascular events, its effect on stroke prevention is unclear, especially in heart failure patients. Atrial cardiopathy is the emerging cause of embolic stroke of unknown source, which indicates atrial structural and functional disorders that can precede AF. Future research should focus on refining stroke risk prediction models, optimizing AF detection, understanding the roles of ablation and anticoagulation in stroke prevention, and establishing atrial cardiopathy as a therapeutic target, which could significantly reduce the burden of stroke.

Diagnostic yield of implantable loop recorders: Results from the Hellenic registry

AIMS

Implantable loop recorders (ILRs) are increasingly being used for long-term cardiac monitoring in different clinical settings. The aim of this study was to investigate the real-world performance of ILRs-including the time to diagnosis- in unselected patients with different ILR indications.

METHODS AND RESULTS

In this multicenter, observational study, 871 patients with an indication of pre-syncope/syncope (61.9%), unexplained palpitations (10.4%), and atrial fibrillation (AF) detection with a history of cryptogenic stroke (CS) (27.7%) underwent ILR implantation. The median follow-up was 28.8 ± 12.9 months. In the presyncope/syncope group, 167 (31%) received a diagnosis established by the device. Kaplan-Meier estimates indicated that 16.9% of patients had a diagnosis at 6 months, and the proportion increased to 22.5% at 1 year. Of 91 patients with palpitations, 20 (22%) received a diagnosis based on the device. The diagnosis established at 12.2% of patients at 6 months, and the proportion increased to 13.3% at 1 year. Among 241 patients with CS, 47 (19.5%) were diagnosed with AF. The diagnostic yield of the device was 10.4% at 6 months and 12.4% at 1 year. In all cases, oral anticoagulation was initiated. Overall, ILR diagnosis altered the therapeutic strategy in 26.1% in presyncope/syncope group, 2.2% in palpitations group, and 3.7% in CS group in addition to oral anticoagulation initiation.

CONCLUSIONS

In this real-world patient population, ILR determines diagnosis and initiates a new therapeutic management in nearly one fourth of patients. ILR implantation is valuable in the evaluation of patients with unexplained presyncope/syncope, CS and palpitations.

Electrocardiogram prediction of atrial fibrillation risk after stroke: A protocol for systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) is one of the most common clinical arrhythmias. This study aims to predict the risk of post-stroke AF through electrocardiographic changes in sinus rhythm.

METHODS

We searched the MEDLINE (PubMed) and EMBASE databases to identify relevant research articles published until August 2023. Prioritized items from systematic reviews and meta-analyses were screened, and data related to AF detection rate were extracted. A meta-analysis using a random-effects model was conducted for data synthesis and analysis.

RESULTS

A total of 32 studies involving electrocardiograms (ECG) were included, with a total analysis population of 330,284 individuals. Among them, 16,662 individuals (ECG abnormal group) developed AF, while 313,622 individuals (ECG normal group) did not. ECG patterns included terminal P-wave terminal force V1, interatrial block (IAB), advanced interatrial block, abnormal P-wave axis, pulse rate prolongation, and atrial premature complexes. Overall, 15,762 patients experienced AF during the study period (4.77%). In the ECG abnormal group, the proportion was 14.21% (2367/16,662), while in the control group (ECG normal group), the proportion was 4.27% (13,395/313,622). The pooled risk ratio for developing AF was 2.45 (95% confidence interval [CI]: 2.02-2.98, P < .001), with heterogeneity (I2) of 95%. The risk ratio values of alAB, P-wave terminal force V1, interatrial block, abnormal P-wave axis, pulse rate prolongation and atrial premature complexes were 4.12 (95% CI, 2.99-5.66), 1.47 (95% CI, 1.19-1.82), 2.54 (95% CI, 1.83-3.52), 1.70 (95% CI, 0.98-2.97), 2.65 (95% CI, 1.88-3.72), 3.79 (95% CI, 2.12-6.76), respectively.

CONCLUSION

There is a significant correlation between ECG patterns and the occurrence of AF. The alAB exhibited the highest level of predictability for the occurrence of AF. These indicators support their use as screening tools to identify high-risk individuals who may benefit from further examinations or empirical anticoagulation therapy following stroke.

Stroke Related Brain-Heart Crosstalk: Pathophysiology, Clinical Implications, and Underlying Mechanisms

The emergence of acute ischemic stroke (AIS) induced cardiovascular dysfunctions as a bidirectional interaction has gained paramount importance in understanding the intricate relationship between the brain and heart. Post AIS, the ensuing cardiovascular dysfunctions encompass a spectrum of complications, including heart attack, congestive heart failure, systolic or diastolic dysfunction, arrhythmias, electrocardiographic anomalies, hemodynamic instability, cardiac arrest, among others, all of which are correlated with adverse outcomes and mortality. Mounting evidence underscores the intimate crosstalk between the heart and the brain, facilitated by intricate physiological and neurohumoral complex networks. The primary pathophysiological mechanisms contributing to these severe cardiac complications involve the hypothalamic-pituitary-adrenal (HPA) axis, sympathetic and parasympathetic hyperactivity, immune and inflammatory responses, and gut dysbiosis, collectively shaping the stroke-related brain-heart axis. Ongoing research endeavors are concentrated on devising strategies to prevent AIS-induced cardiovascular dysfunctions. Notably, labetalol, nicardipine, and nitroprusside are recommended for hypertension control, while β-blockers are employed to avert chronic remodeling and address arrhythmias. However, despite these therapeutic interventions, therapeutic targets remain elusive, necessitating further investigations into this complex challenge. This review aims to delineate the state-of-the-art pathophysiological mechanisms in AIS through preclinical and clinical research, unraveling their intricate interplay within the brain-heart axis, and offering pragmatic suggestions for managing AIS-induced cardiovascular dysfunctions.

Age-Dependent Detection of Atrial Fibrillation with Implantable Cardiac Monitors in Patients with Cryptogenic Stroke

Background  Continuous monitoring using implantable cardiac monitors (ICMs) results in atrial fibrillation (AF) detection rates of up to 30% in patients with cryptogenic stroke (CS). Although higher age is an independent risk factor for AF, there are no age-specific recommendations for the implantation of ICM. Objective  The aim of this study was to analyze age-related AF rates in patients with CS and continuous rhythm monitoring, to determine the rates of oral anticoagulation (OAC) and recurrent cerebrovascular events (stroke or transient ischemic attack) in patients with ICM-detected AF, and to describe the temporal relationship of AF detection and recurrent cerebrovascular events. Methods  In this observational study, patients with CS provided with ICMs were systematically followed. All patients underwent 72-hour electrocardiography monitoring, transcranial Doppler ultrasound, and transthoracic echocardiography prior to ICM insertion. Follow-up included a regular outpatient presentation every 3 months with medical history, physical examination, and interrogation of the ICM. Results  One-hundred eighty-six patients (mean age: 65 ± 12 years, 54% female) were included in this analysis. AF was detected in 6, 27, 56, and 65% ( p  < 0.001) of patients aged less than 60, 60 to 69, 70 to 79, and more than or equal to 80 years, respectively. All patients with AF under 60 years had an impaired left ventricular systolic function. OAC was initiated in 85% of the patients with AF. Recurrent cerebrovascular events occurred in 34 patients of whom 14 had a diagnosis of AF. In nine patients, AF was diagnosed before the occurrence of a recurrent cerebrovascular event. Conclusion  AF prevalence increased with age and was absent in CS patients younger than 60 years and with preserved left ventricular ejection fraction. The temporal relationship of AF and recurrent cerebrovascular events was weak.

Thin aortic arch plaque is associated with the development of atrial fibrillation for embolic stroke of undetermined source in patients with an insertable cardiac monitor

BACKGROUND AND OBJECTIVE

This study's objective is to investigate whether mild aortic arch plaque is associated with the development of atrial fibrillation (AF) in stroke patients with embolic stroke of undetermined source (ESUS) during the first year following the implantation of an insertable cardiac monitor (ICM).

METHODS

The participants in this cross-sectional observational study were consecutive patients with ESUS, even after transesophageal echocardiography. We assessed the relationship between the thickness of the participants' aortic arch plaque and AF detected after ICM implantation.

RESULTS

Of the 50 consecutive patients with ESUS enrolled in this study, 12 (24%) developed AF. We observed that thicker aortic arch plaque was associated with undetected AF (2.3 mm vs. 1.2 mm, p < 0.001). Aortic arch plaque thickness was independent associated with undetected AF (OR 54.00, 95% CI 2.706-1077.544, p = 0.009). When the cut-off value for aortic arch plaque thickness was 1.8 mm, the sensitivity and specificity were 71.1% and 91.7%, respectively (95% CI = 0.75-0.98, p < 0.001). Also, patients having both aortic arch plaque with a thickness < 1.8 mm and a CHADS2 score ≥ 4 were more likely to have detectable AF than no AF (88% vs. 12%, p < 0.001).

CONCLUSION

A thinner aortic arch plaque was associated with the development of AF. Patients with mild aortic plaques below 4 mm but ≥1.8 mm in thickness and without other high-risk features are less likely to have paroxysmal AF on ICM, and these plaques may be a possible source of embolism for their strokes.

Predictors of atrial fibrillation detection in embolic stroke of undetermined source patients with implantable loop recorder

Background

Covert atrial fibrillation (AF) is a predominant aetiology of embolic stroke of undetermined source (ESUS). Evidence suggested that AF is more frequently detected by implantable loop recorder (ILR) than by conventional monitoring. However, the predictive factors associated with occult AF detected using ILRs are not well established yet. In this study we aim to investigate the predictors of AF detection in patients with ESUS undergoing an ILR.

Methods

This observational multi-centre study included consecutive ESUS patients who underwent ILR implantation. The infarcts were divided in deep, cortical infarcts or both. The infarction sites were categorized as anterior and middle cerebral artery, posterior cerebral artery with and without brainstem/cerebellum involvement. Multivariable logistic regression analysis was performed to investigate variables associated with AF detection.

Results

Overall, 3,000 patients were initially identified. However, in total, 127 patients who consecutively underwent ILR implantation were included in our analysis. AF was detected in 33 (26%) out of 127 patients. The median follow-up was 411 days. There were no significant differences in clinical characteristics and comorbidities between patients with and without AF detected. AF was detected more often after posterior cerebral artery infarct with brainstem/cerebellum involvement (p < 0.001) whereas less often after infarction in the anterior and middle cerebral artery (p = 0.021). Multivariable regression analysis demonstrated that posterior cerebral artery infarct with brainstem/cerebellum involvement was an independent predictor of AF detection.

Conclusion

Our study showed that posterior circulation infarcts with brainstem/cerebellum involvement are associated with AF detection in ESUS patients undergoing ILR. Larger prospective studies are needed to validate our findings.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Value of HAVOC and Brown ESUS-AF scores for atrial fibrillation on implantable cardiac monitors after embolic stroke of undetermined source

OBJECTIVES

Up to 20 % of ischemic strokes are associated with overt atrial fibrillation (AF). Furthermore, silent AF was detected by an implantable cardiac monitor (ICM) in 1 in 3 cryptogenic strokes in the CRYSTAL AF study. An ESC position paper has suggested a HAVOC score ≥ 4 or a Brown ESUS-AF score ≥ 2 as criteria for ICM implantation after cryptogenic stroke, but neither of these criteria has been developed or validated in ICM populations. We assessed the performance of HAVOC and Brown ESUS-AF scores in a cohort of ICM patients implanted after embolic stroke of undetermined source (ESUS).

METHODS

All patients implanted with an ICM for ESUS between February 2016 and February 2022 at two French University Hospitals were retrospectively included. Demographic data, cardiovascular risk factors, and clinical and biological data were collected after a review of electronic medical records. HAVOC and Brown ESUS-AF scores were calculated for all patients.

FINDINGS

Among the 384 patients included, 106 (27 %) developed AF during a mean follow-up of 33 months. The scores performances for predicting AF during follow-up were: HAVOC= AUC: 68.5 %, C-Index: 0.662, and Brown ESUS-AF=AUC: 72.9 %, C-index 0.712. Compared with the CHA2DS2-VASc score, only the Brown ESUS-AF score showed significant improvement in NRI/IDI. Furthermore, classifying patients according to the suggested HAVOC and Brown ESUS-AF thresholds, only 24 % and 31 % of the cohort, respectively, would have received an ICM, and 58 (55 %) and 47 (44 %) of the AF patients, respectively, would not have been implanted with an ICM.

CONCLUSION

HAVOC and Brown ESUS-AF scores showed close and moderate performance in predicting AF on ICM after cryptogenic stroke, with a significant lack of sensitivity. Specific risk scores should be developed and validated in large ICM cohorts.

Atrial Fibrillation Detection and Load: Knowledge Gaps Related to Stroke Prevention

Atrial fibrillation is a major cause of ischemic stroke. Technological advances now support prolonged cardiac rhythm monitoring using either surface electrodes or insertable cardiac monitors. Four major randomized controlled trials show that prolonged cardiac monitoring detects subclinical paroxysmal atrial fibrillation in 9% to 16% of patients with ischemic stroke, including in patients with potential alternative causes such as large artery disease or small vessel occlusion; however, the optimal monitoring strategy, including the target patient population and the monitoring device (whether to use an event monitor, insertable cardiac monitor, or stepped approach) has not been well defined. Furthermore, the clinical significance of very short duration paroxysmal atrial fibrillation remains controversial. The relevance of the duration of monitoring, burden of device-detected atrial fibrillation, and its proximity to the acute ischemic stroke will require more research to define the most effective methods for stroke prevention in this patient population.

Towards a new classification of atrial fibrillation detected after a stroke or a transient ischaemic attack

Globally, up to 1·5 million individuals with ischaemic stroke or transient ischaemic attack can be newly diagnosed with atrial fibrillation per year. In the past decade, evidence has accumulated supporting the notion that atrial fibrillation first detected after a stroke or transient ischaemic attack differs from atrial fibrillation known before the occurrence of as stroke. Atrial fibrillation detected after stroke is associated with a lower prevalence of risk factors, cardiovascular comorbidities, and atrial cardiomyopathy than atrial fibrillation known before stroke occurrence. These differences might explain why it is associated with a lower risk of recurrence of ischaemic stroke than known atrial fibrillation. Patients with ischaemic stroke or transient ischaemic attack can be classified in three categories: no atrial fibrillation, known atrial fibrillation before stroke occurrence, and atrial fibrillation detected after stroke. This classification could harmonise future research in the field and help to understand the role of prolonged cardiac monitoring for secondary stroke prevention with application of a personalised risk-based approach to the selection of patients for anticoagulation.

Apixaban versus Aspirin for Embolic Stroke of Undetermined Source

BACKGROUND: Rivaroxaban and dabigatran were not superior to aspirin in trials of patients with embolic stroke of undetermined source (ESUS). It is unknown whether apixaban is superior to aspirin in patients with ESUS and known risk factors for cardioembolism. METHODS: We conducted a multicenter, randomized, open-label, blinded-outcome trial of apixaban (5 mg twice daily) compared with aspirin (100 mg once daily) initiated within 28 days after ESUS in patients with at least one predictive factor for atrial fibrillation or a patent foramen ovale. Cardiac monitoring was mandatory, and aspirin treatment was switched to apixaban in case of atrial fibrillation detection. The primary outcome was any new ischemic lesion on brain magnetic resonance imaging (MRI) during 12-month follow-up. Secondary outcomes included major and clinically relevant nonmajor bleeding. RESULTS: A total of 352 patients were randomly assigned to receive apixaban (178 patients) or aspirin (174 patients) at a median of 8 days after ESUS. At 12-month follow-up, MRI follow-up was available in 325 participants (92.3%). New ischemic lesions occurred in 23 of 169 (13.6%) participants in the apixaban group and in 25 of 156 (16.0%) participants in the aspirin group (adjusted odds ratio, 0.79; 95% confidence interval, 0.42 to 1.48; P=0.57). Major and clinically relevant nonmajor bleeding occurred in five and seven participants, respectively (1-year cumulative incidences, 2.9 and 4.2; hazard ratio, 0.68; 95% confidence interval, 0.22 to 2.16). Serious adverse event rates were 43.9 per 100 person-years in those given apixaban and 45.7 per 100 person-years in those given aspirin. The Apixaban for the Treatment of Embolic Stroke of Undetermined Source trial was terminated after a prespecified interim analysis as a result of futility. CONCLUSIONS: Apixaban treatment was not superior to cardiac monitoring-guided aspirin in preventing new ischemic lesions in an enriched ESUS population. (Funded by Bristol-Myers Squibb and Medtronic Europe; ClinicalTrials.gov number, NCT02427126.)

Evaluation of organized atrial arrhythmias after cryptogenic stroke

Background

Long-term rhythm monitoring to detect atrial fibrillation (AF) following a cryptogenic stroke (CS) is well established. However, the burden of organized atrial arrhythmias in this population is not well defined.

Objective

The purpose of this study was to assess the incidence and risk factors for organized atrial arrhythmias in patients with CS.

Methods

We evaluated all patients with CS who received an insertable cardiac monitor (ICM) between October 2014 and April 2020. All ICM transmissions categorized as AF, tachycardia, or bradycardia were reviewed. We evaluated the time to detection of organized AF and the combination of either organized atrial arrhythmia or AF.

Results

A total of 195 CS patients with ICMs were included (51% men; mean age 66 ± 12 years; mean CHA2DS2-VASC score 4.6). Over mean follow-up of 18.9 ± 11.2 months, organized atrial arrhythmias lasting ≥30 seconds were detected in 45 patients (23%), of whom 62% did not have AF. Seventeen patients had both organized atrial arrhythmia and AF, and another 21 patients had AF only. Compared to those with normal left atrial size, patients with left atrial enlargement had a higher adjusted risk for development of atrial arrhythmias (mild left atrial enlargement: hazard ratio 1.99; 95% confidence interval 1.06-3.75; moderate/severe left atrial enlargement: hazard ratio 3.06; 95% confidence interval 1.58-5.92).

Conclusion

Organized atrial arrhythmias lasting ≥30 seconds are detected in nearly one-fourth of CS patients. Two-thirds of these patients did not have AF. Further studies are required to evaluate the impact of organized atrial arrhythmias on recurrent stroke risk.

Technology engagement is associated with higher perceived physical well-being in stroke patients prescribed smartwatches for atrial fibrillation detection

Background

Increasing ownership of smartphones among Americans provides an opportunity to use these technologies to manage medical conditions. We examine the influence of baseline smartwatch ownership on changes in self-reported anxiety, patient engagement, and health-related quality of life when prescribed smartwatch for AF detection.

Method

We performed a post-hoc secondary analysis of the Pulsewatch study (NCT03761394), a clinical trial in which 120 participants were randomized to receive a smartwatch-smartphone app dyad and ECG patch monitor compared to an ECG patch monitor alone to establish the accuracy of the smartwatch-smartphone app dyad for detection of AF. At baseline, 14 days, and 44 days, participants completed the Generalized Anxiety Disorder-7 survey, the Health Survey SF-12, and the Consumer Health Activation Index. Mixed-effects linear regression models using repeated measures with anxiety, patient activation, physical and mental health status as outcomes were used to examine their association with smartwatch ownership at baseline.

Results

Ninety-six participants, primarily White with high income and tertiary education, were randomized to receive a study smartwatch-smartphone dyad. Twenty-four (25%) participants previously owned a smartwatch. Compared to those who did not previously own a smartwatch, smartwatch owners reported significant greater increase in their self-reported physical health (β = 5.07, P < 0.05), no differences in anxiety (β = 0.92, P = 0.33), mental health (β = -2.42, P = 0.16), or patient activation (β = 1.86, P = 0.54).

Conclusions

Participants who own a smartwatch at baseline reported a greater positive change in self-reported physical health, but not in anxiety, patient activation, or self-reported mental health over the study period.

Paroxysmal Atrial Fibrillation (PFA) Detection With Cardiac Monitoring Devices Implanted by Neurologists in Patients With Embolic Strokes of Undetermined Source (ESUS)

Introduction Ischemic stroke is among the leading causes of death and disability. Approximately 50% of cryptogenic strokes are embolic strokes of undetermined source (ESUS). The most common cause of ESUS is atrial fibrillation. Therefore, the detection of atrial fibrillation with long-term implantable devices is needed. Neurologists are directly involved with acute and post-acute stroke care and have direct access to the management of stroke patients. Therefore, there is a need for neurologists to recommend, implant, and monitor cardiac implantable devices in patients with ESUS. Methods From November 2022 to October 2023, our group implanted 32 ESUS patients with Confirm Rx™ insertable cardiac monitors (Abbott, USA). Atrial fibrillation detection was supervised and monitored daily. Results In 24 months, atrial fibrillation was detected in 12.5% of patients (four patients), sinus bradycardia in 6.25% of patients (two patients), paroxysmal supraventricular tachycardia in 9.4% of patients (three patients), and asystole in one patient. Conclusion Our study shows that neurologists involved in the treatment of stroke care can safely implant, monitor, and detect atrial fibrillation accurately. Our rate of detection of atrial fibrillation in patients with ESUS was 12.8%, which is consistent with prior studies.

Atrial Fibrillation In Patients With Stroke Attributed to Large- or Small-Vessel Disease: 3-Year Results From the STROKE AF Randomized Clinical Trial

Importance

The STROKE AF study found that in patients with prior ischemic stroke attributed to large-artery atherosclerotic disease (LAD) or small-vessel occlusive disease (SVD), 12% developed AF over 1 year when monitored with an insertable cardiac monitor (ICM). The occurrence over subsequent years is unknown.

Objectives

To compare the rates of AF detection through 3 years of follow-up between an ICM vs site-specific usual care in patients with prior ischemic stroke attributed to LAD or SVD.

Design, Setting, and Participants

This multicenter, randomized (1:1) clinical trial took place at 33 sites in the US with enrollment between April 2016 and July 2019 and 3-year follow-up through July 2022. Eligible patients were aged 60 years or older, or aged 50 to 59 years with at least 1 additional stroke risk factor and had an index ischemic stroke attributed to LAD or SVD within 10 days prior to ICM insertion. Of the 496 patients enrolled, 492 were randomized and 4 were excluded.

Interventions

ICM monitoring vs site-specific usual care.

Main Outcomes and Measures

The prespecified long-term outcome of the trial was AF detection through study follow-up (up to 3 years). AF was defined as an episode lasting more than 30 seconds, adjudicated by an expert committee.

Results

In total, 492 patients were randomized and included in the analyses (median [IQR] age, 66 [60-74] years; 307 men [62.4%] and 185 women [37.6%]), of whom 314 completed 3-year follow-up (63.8%). The incidence rate of AF at 3 years was 21.7% (46 patients) in the ICM group vs 2.4% (5 patients) in the control group (hazard ratio, 10.0; 95% CI, 4.0-25.2; P < .001).

Conclusions and Relevance

Patients with ischemic stroke attributed to LAD or SVD face an increasing risk of AF over time and most of the AF occurrences are not reliably detected by standard medical monitoring methods. One year of negative monitoring should not reassure clinicians that patients who have experienced stroke will not develop AF over the next 2 years.

Trial Registration

ClinicalTrials.gov Identifier: NCT02700945.

Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care

Reperfusion therapy in the form of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) has revolutionised the field of stroke medicine. Atrial fibrillation (AF) patients constitute a major portion of the overall stroke population; however, the prevalence of AF amongst acute ischemic stroke (AIS) patients receiving reperfusion therapy remains unclear. Limitations in our understanding of prevalence in this group of patients are exacerbated by difficulties in appropriately diagnosing AF. Additionally, the benefits of reperfusion therapy are not consistent across all subgroups of AIS patients. More specifically, AIS patients with AF often tend to have poor prognoses despite treatment relative to those without AF. This article aims to present an overview of the diagnostic and therapeutic management of AF and how it mediates outcomes following stroke, most specifically in AIS patients treated with reperfusion therapy. We provide unique insights into AF prevalence and outcomes that could allow healthcare professionals to optimise the treatment and prognosis for AIS patients with AF. Specific indications on acute neurovascular management and secondary stroke prevention in AIS patients with AF are also discussed.

Intensive heart rhythm monitoring to decrease ischemic stroke and systemic embolism-the Find-AF 2 study-rationale and design

BACKGROUND

Atrial fibrillation (AF) is one of the most frequent causes of stroke. Several randomized trials have shown that prolonged monitoring increases the detection of AF, but the effect on reducing recurrent cardioembolism, ie, ischemic stroke and systemic embolism, remains unknown. We aim to evaluate whether a risk-adapted, intensified heart rhythm monitoring with consequent guideline conform treatment, which implies initiation of oral anticoagulation (OAC), leads to a reduction of recurrent cardioembolism.

METHODS

Find-AF 2 is a randomized, controlled, open-label parallel multicenter trial with blinded endpoint assessment. 5,200 patients ≥ 60 years of age with symptomatic ischemic stroke within the last 30 days and without known AF will be included at 52 study centers with a specialized stroke unit in Germany. Patients without AF in an additional 24-hour Holter ECG after the qualifying event will be randomized in a 1:1 fashion to either enhanced, prolonged and intensified ECG-monitoring (intervention arm) or standard of care monitoring (control arm). In the intervention arm, patients with a high risk of underlying AF will receive continuous rhythm monitoring using an implantable cardiac monitor (ICM) whereas those without high risk of underlying AF will receive repeated 7-day Holter ECGs. The duration of rhythm monitoring within the control arm is up to the discretion of the participating centers and is allowed for up to 7 days. Patients will be followed for at least 24 months. The primary efficacy endpoint is the time until recurrent ischemic stroke or systemic embolism occur.

CONCLUSIONS

The Find-AF 2 trial aims to demonstrate that enhanced, prolonged and intensified rhythm monitoring results in a more effective prevention of recurrent ischemic stroke and systemic embolism compared to usual care.

Predictors of Atrial Fibrillation in Patients with Embolic Stroke of Unknown Etiology and Implantable Loop Recorders-Further Insights of the TRACK AF Study on the Role of ECG and Echocardiography

Aims-Electrocardiography (ECG) and echocardiographic left atrial (LA) parameters may be helpful to assess the risk of atrial fibrillation (AF) in embolic stroke of unknown etiology (ESUS) and could therefore guide intensity of ECG monitoring. Methods-1153 consecutive patients with ischemic stroke or transient ischemic attack (TIA) were analyzed. An internal loop recorder (ILR) was implanted in 104 consecutive patients with ESUS. Multiple morphologic P-wave parameters in baseline 12-channel ECG and echocardiographic LA parameters were measured and analyzed in patients with and without ILR-detected AF. Using logistic regression, we evaluated the predictive value of several ECG parameters and LA dimensions on the occurrence of AF. Results-In 20 of 104 (19%) patients, AF was diagnosed by ILR during a mean monitoring time of 575 (IQR 470-580) days. Patients with AF were significantly older (72 (67-75) vs. 60 (52-72) years; p = 0.001) and premature atrial contractions (PAC) were more frequently observed (40% vs. 2%; p < 0.001) during baseline ECG. All morphologic P-wave parameters did not show a significant difference between groups. There was a non-significant trend towards a larger LA volume index (31 (24-36) vs. 29 (25-37) mL/m2; p = 0.09) in AF patients. Conclusions-Age and PAC are independently associated with incident AF in ESUS and could be used as markers for selecting patients that may benefit from more extensive rhythm monitoring or ILR implantation. In our consecutive cohort of patients with ESUS, neither morphological P-wave parameters nor LA size were predictive of AF.

Comparison of the 11-Day Adhesive ECG Patch Monitor and 24-h Holter Tests to Assess the Response to Antiarrhythmic Drug Therapy in Paroxysmal Atrial Fibrillation

Accurate assessment of the response to the antiarrhythmic drug (AAD) in atrial fibrillation (AF) is crucial to achieve adequate rhythm control. We evaluated the effectiveness of extended cardiac monitoring using an adhesive ECG patch in the detection of drug-refractory paroxysmal AF. Patients diagnosed with paroxysmal AF and receiving AAD therapy were enrolled. The subjects simultaneously underwent 11-day adhesive ECG patch monitoring and a 24-h Holter test. The primary study outcome was a detection rate of drug-refractory AF or atrial tachycardia (AT) lasting ≥30 s. A total of 59 patients were enrolled and completed the study examinations. AF or AT was detected in 28 (47.5%) patients by an 11-day ECG patch monitor and in 8 (13.6%) patients by a 24-h Holter test (p < 0.001). The 11-day ECG patch monitor identified an additional 20 patients (33.8%) with drug-refractory AF not detected by the 24-h Holter, and as a result, the treatment plan was changed in 11 patients (10 catheter ablations, one medication change). In conclusion, extended cardiac rhythm monitoring using an adhesive ECG patch in patients with paroxysmal AF under AAD therapy led to over a threefold higher detection of drug-refractory AF episodes, compared to the 24-h Holter test.

Advances in Cardiac Workup for Transient Ischemic Attack: Improving Diagnostic Yield and Reducing Recurrent Stroke Risk

Transient ischemic attack (TIA) is a warning sign for an impending stroke, with a 10-20% chance of a stroke occurring within 90 days of the initial event. Current clinical practice for cardiac workup in TIA includes cardiac enzymes, with 12-lead electrocardiogram, transthoracic echocardiography, and 24-hour Holter monitoring. However, the diagnostic yield of these investigations is variable, and there is a need for better diagnostic approaches to increase the detection of cardiac abnormalities in a cost-effective way. This review article examines the latest research on emerging diagnostic tools and strategies and discusses the potential benefits and challenges of using these advanced diagnostic approaches in clinical practice. Novel biomarkers, imaging techniques, and prolonged rhythm monitoring devices have shown great promise in enhancing the diagnostic yield of cardiac workup in TIA patients. Echocardiography, Transcranial Doppler ultrasound, cardiac MRI, and cardiac CT are among the promising diagnostic tools being studied. We conclude the article with a suggested diagnostic algorithm for cardiac workup in TIA. Further research is necessary to enhance their usefulness and to outline future directions for research and clinical practice in this field.

Atrial Fibrillation and Reperfusion Therapy in Acute Ischaemic Stroke Patients: Prevalence and Outcomes-A Comprehensive Systematic Review and Meta-Analysis

Atrial fibrillation (AF) significantly contributes to acute ischaemic stroke (AIS), yet its precise influence on clinical outcomes post-intravenous thrombolysis (IVT) and post-endovascular thrombectomy (EVT) has remained elusive. Furthermore, the overall prevalence of AF in AIS patients undergoing reperfusion therapy has not been clearly determined. Employing random-effects meta-analyses, this research aimed to estimate the pooled prevalence of AF among AIS patients undergoing reperfusion therapy, while also examining the association between AF and clinical outcomes such as functional outcomes, symptomatic intracerebral haemorrhage (sICH) and mortality. Studies comparing AF and non-AF patient groups undergoing reperfusion therapy were identified and included following an extensive database search. Forty-nine studies (n = 66,887) were included. Among IVT patients, the prevalence of AF was 31% (Effect Size [ES] 0.31 [95%CI 0.28-0.35], p < 0.01), while in EVT patients, it reached 42% (ES 0.42 [95%CI 0.38-0.46], p < 0.01), and in bridging therapy (BT) patients, it stood at 36% (ES 0.36 [95%CI 0.28-0.43], p < 0.01). AF was associated with significantly lower odds of favourable 90-day functional outcomes post IVT (Odds Ratio [OR] 0.512 [95%CI 0.376-0.696], p < 0.001), but not post EVT (OR 0.826 [95%CI 0.651-1.049], p = 0.117). Our comprehensive meta-analysis highlights the varying prevalence of AF among different reperfusion therapies and its differential impact on patient outcomes. The highest pooled prevalence of AF was observed in EVT patients, followed by BT and IVT patients. Interestingly, our analysis revealed that AF was significantly associated with poorer clinical outcomes following IVT. Such an association was not observed following EVT.

Prevalence and Factors Associated with Atrial Fibrillation in Patients with Transient Ischemic Attack or Ischemic Stroke in Northern Vietnam

BACKGROUND

The prevalence and risk factors of atrial fibrillation (AF) in patients with transient ischemic attack (TIA) or ischemic stroke in Northern Vietnam are not well understood. This study aimed to estimate the prevalence and identify factors associated with AF in this population.

METHODS

A cross-sectional study was conducted on 2038 consecutive patients with TIA or ischemic stroke admitted to Bach Mai Hospital. AF was diagnosed using an electrocardiogram or Holter monitor. Logistic regression analyses were performed to determine the association between AF and risk factors.

RESULTS

Among the patients, 18.1% (95% CI: 16.46 to 19.85) had AF. Older age, renal dysfunction, valvular heart disease (VHD), and low ejection fraction were significantly associated with AF. Advanced age (per 10 years) (adjusted OR, aOR 1.39; 95% CI, 1.23 to 1.57), estimated glomerular filtration ratio decrease (per 10 mL/min/1.73 m2) (aOR 1.12; 95% CI, 1.06 to 1.17), VHD (aOR 9.59; 95% CI, 7.10 to 12.95), and low ejection fraction (<50%) (aOR 2.61; 95% CI, 1.62 to 4.21) had notable odds ratios for AF.

CONCLUSIONS

Atrial fibrillation is prevalent among patients with TIA or ischemic stroke in Northern Vietnam, surpassing rates in other Southeast Asian countries. Age, renal dysfunction, VHD, and low ejection fraction were significant risk factors for AF in this population.

Stroke Recurrence in Embolic Stroke of Undetermined Source Without Atrial Fibrillation on Invasive Cardiac Monitoring

BACKGROUND

More than half of patients with embolic stroke of undetermined source (ESUS) suffer from recurrent ischaemic stroke, despite the absence of atrial fibrillation (AF) on invasive cardiac monitoring (ICM). This study investigated the predictors and prognosis of recurrent stroke in ESUS without AF on ICM.

METHOD

This prospective study included patients with ESUS at two tertiary hospitals from 2015 to 2021 who underwent comprehensive neurological imaging, transthoracic echocardiography, and inpatient continuous electrographic monitoring for ≥48 hours prior to ICM for definitive exclusion of AF. Recurrent ischaemic stroke, all-cause mortality, and functional outcome by the modified Rankin scale (mRS) at 3 months were evaluated in patients without AF.

RESULTS

Of 185 consecutive patients with ESUS, AF was not detected in 163 (88%) patients (age 62±12 years, 76% men, 25% prior stroke, median time to ICM insertion 26 [7, 123] days), and stroke recurred in 24 (15%) patients. Stroke recurrences were predominantly ESUS (88%), within the first 2 years (75%), and involved a different vascular territory from qualifying ESUS (58%). Pre-existing cancer was the only independent predictor of recurrent stroke (adjusted hazard ratio [AHR] 5.43, 95% CI 1.43-20.64), recurrent ESUS (AHR 5.67, 95% CI 1.15-21.21), and higher mRS score at 3 months (ß 1.27, 95% CI 0.23-2.42). All-cause mortality occurred in 17 (10%) patients. Adjusting for age, cancer, and mRS category (≥3 vs <3), recurrent ESUS was independently associated with more than four times greater hazard of death (AHR 4.66, 95% CI 1.76-12.34).

CONCLUSIONS

Patients with recurrent ESUS are a high-risk subgroup. Studies elucidating optimal diagnostic and treatment strategies in non-AF-related ESUS are urgently required.

Anxiety, patient activation, and quality of life among stroke survivors prescribed smartwatches for atrial fibrillation monitoring

Background

The detection of atrial fibrillation (AF) in stroke survivors is critical to decreasing the risk of recurrent stroke. Smartwatches have emerged as a convenient and accurate means of AF diagnosis; however, the impact on critical patient-reported outcomes, including anxiety, engagement, and quality of life, remains ill defined.

Objectives

To examine the association between smartwatch prescription for AF detection and the patient-reported outcomes of anxiety, patient activation, and self-reported health.

Methods

We used data from the Pulsewatch trial, a 2-phase randomized controlled trial that included participants aged 50 years or older with a history of ischemic stroke. Participants were randomized to use either a proprietary smartphone-smartwatch app for 30 days of AF monitoring or no cardiac rhythm monitoring. Validated surveys were deployed before and after the 30-day study period to assess anxiety, patient activation, and self-rated physical and mental health. Logistic regression and generalized estimation equations were used to examine the association between smartwatch prescription for AF monitoring and changes in the patient-reported outcomes.

Results

A total of 110 participants (mean age 64 years, 41% female, 91% non-Hispanic White) were studied. Seventy percent of intervention participants were novice smartwatch users, as opposed to 84% of controls, and there was no significant difference in baseline rates of anxiety, activation, or self-rated health between the 2 groups. The incidence of new AF among smartwatch users was 6%. Participants who were prescribed smartwatches did not have a statistically significant change in anxiety, activation, or self-reported health as compared to those who were not prescribed smartwatches. The results held even after removing participants who received an AF alert on the watch.

Conclusion

The prescription of smartwatches to stroke survivors for AF monitoring does not adversely affect key patient-reported outcomes. Further research is needed to better inform the successful deployment of smartwatches in clinical practice.

Detection of Atrial Fibrillation after Ischemic Stroke with an Insertable Cardiac Monitor: A Systematic Review and Individual Patient Data Meta-Analysis of Randomized Clinical Trials

INTRODUCTION

We compared the use of insertable cardiac monitor (ICM) versus non-ICM methods of cardiac monitoring in ischemic stroke patients on the detection of atrial fibrillation (AF) and other clinical outcomes. Current guidelines recommend the routine use of 12-lead electrocardiography or Holter monitoring for AF detection after ischemic stroke. Recent randomized controlled trials have investigated the impact of ICM versus non-ICM methods of cardiac monitoring for AF detection in this population. However, precise recommendations for monitoring poststroke AF are lacking, including the optimal timing, duration, and method of electrocardiography monitoring.

METHODS

A systematic search was conducted on Embase and PubMed from database inception until October 27, 2022, to include randomized controlled trials that compared ICM with non-ICM methods of cardiac monitoring for poststroke AF detection. This yielded 3 randomized controlled trials with a combined cohort of 1,233 patients with a recent ischemic stroke. Individual patient data (IPD) were then reconstructed from Kaplan-Meier curves and analyzed using the shared-frailty Cox model. An aggregate data meta-analysis was conducted for 1,233 patients across all 3 studies for outcomes that could not be reconstructed using IPD.

RESULTS

One-stage meta-analysis demonstrated an increase in the hazard ratio (6.00 95% CI: 3.40-10.58; 195 p < 0.001) of AF detection in patients undergoing monitoring via ICM compared to standard care. The cumulative incidence curves of AF events in patients undergoing ICM and non-ICM separated significantly at 24 days. Aggregate data meta-analysis revealed a significant increase in initiation of anticoagulation (RR: 2.76, 95% CI: 1.89-4.02, p < 0.00001) in the ICM group. However, no significant differences in the incidence of recurrent ischemic stroke, transient ischemic attack, or death were found.

CONCLUSIONS

In this meta-analysis, we found that the use of ICM increased the detection rate of poststroke AF and the rate of anticoagulation initiation in ischemic stroke patients. However, this did not translate into a reduced incidence of recurrent ischemic stroke.

Searching for atrial fibrillation post stroke: is it time for digital devices?

The detection of atrial fibrillation (AF) in patients with cryptogenic stroke (CS) is an essential part of management to limit the risk of recurrence. However, in practice, not all patients who need AF screening are screened, or are screened with significant delays. The disparities of access to examinations, their costs as well as the increasing workload require an evolution of practices both in terms of organization and the type of equipment used. The ubiquity and ease of use of digital devices, together with their evaluation in large population and their expected lower cost, make them attractive as potential alternatives to current equipment at all stages of patient management. However, reliability and accuracy of each digital device for the detection of paroxysmal AF in CS patients should be established before consideration for inclusion in clinical practice. The aim of this short analysis is therefore to review the current practical issues for AF detection in post stroke patients, the potential benefits and issues using digital devices in stroke patients and to position the different digital devices as alternative to standard equipment at each stage of stroke patient pathway. This may help to design future studies for the evaluation of these devices in this context. Under this condition, the time for digital devices to detect AF after stroke seems very close.

Effect of implantable cardiac monitors on preventing stroke: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND AND AIM

Implantable cardiac monitors (ICM) can facilitate the detection of asymptomatic atrial fibrillation episodes. We performed a systematic review and meta-analysis to investigate whether ICM can prevent stroke in patients with prior stroke and risk factors for stroke.

METHODS

This study included randomized controlled trials comparing ICM with conventional (non-ICM) external cardiac monitoring in patients with prior stroke and risk factors for stroke. We searched Medline, Embase, and CENTRAL from inception until January 5, 2022, without language restriction. Quantitative pooling of the data was undertaken using a random-effects model. The primary outcome was ischemic stroke at the longest follow-up.

RESULTS

Four trials comprising 7237 patients were included. ICM was significantly associated with decreased risk of ischemic stroke (RR 0.76; 95% CI, 0.59-0.97; moderate-quality evidence) in patients with prior stroke and risk factors for stroke. ICM was associated with higher detection of atrial fibrillation (RR 4.21, 95% CI 2.26-7.85) and use of oral anticoagulants (RR 2.29, 95% CI 2.07-2.55).

CONCLUSIONS

ICM results in a significantly lower risk of ischemic stroke than conventional (non-ICM) external cardiac monitoring in patients with prior stroke and risk factors for stroke. Due to the clinical heterogeneity of study population and limited related studies, more trials were needed to furtherly explore the topic in patients with prior stroke or high risk of stroke.

ECG Smart Monitoring versus Implantable Loop Recorders for Atrial Fibrillation Detection after Cryptogenic Stroke-An Overview for Decision Making

Up to 20% of patients with ischemic stroke or transient ischemic attack have a prior history of known atrial fibrillation (AF). Additionally, unknown AF can be detected by different monitoring strategies in up to 23% of patients with cryptogenic or non-cardioembolic stroke. However, most studies had substantial gaps in monitoring time, especially early after the index event. Following this, AF rates would be higher if patients underwent continuous monitoring early after stroke, avoiding any gaps in monitoring. The few existing randomized studies focused on patients with cryptogenic stroke but did not focus otherwise specifically on prevention strategies in patients at high risk for AF (patients at higher age or with high CHA2DS2-VASC scores). Besides invasive implantable loop recorders (ILRs), external loop recorders (ELRs) and mobile cardiac outpatient telemetry (MCOT) are non-invasive tools that are commonly used for long-term ECG monitoring in cryptogenic-stroke patients in the ambulatory setting. The role of MCOT and hand-held devices within ECG smart monitoring in the detection of AF for the prevention of and after cryptogenic stroke is currently unclear. This intense review provides an overview of current evidence, techniques, and gaps in knowledge and aims to advise which patients benefit most from the current available devices.

Remote Patient Monitoring: What Have We Learned and Where Are We Going?

Purpose of Review

Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is an important part of patient follow-up. The increasing number of patients with CIEDs and the recent pandemic pose several challenges for already limited device clinic resources. This review focuses on recent evolutions in RM and identifies future needs to improve RM.

Recent Findings

RM has been associated with multiple clinical benefits, including improved survival, early detection of actionable events, reduction in inappropriate shocks, longer battery lives, and more efficient healthcare utilization. The survival benefit was driven by studies using alert-based continuous RM with daily transmissions and fast reaction times. Patients report a high satisfaction rate without significant differences in quality of life between RM and in-office follow-up.The increasing workload, due to the increasing number of CIEDs implanted with daily remote transmissions, results in several challenges for the future of RM. RM requires appropriate reimbursement for RM device clinics to optimize patient/staff ratios, including sufficient non-clinical and administrative support. Universal alert programming and data processing may minimize inter-manufacturer differences, improve the signal-to-noise ratio, and allow the development of standard operating protocols and workflows. In the future, programming by remote control and true remote programming may further improve remote CIED management, patient quality of life, and device clinic workflows.

Summary

RM should be considered standard of care in management of patients with CIEDs. The clinical benefits of RM can be maximized by an alert-based continuous RM model. Adapted healthcare policies are required to keep RM manageable for the future.

Monitoring for atrial fibrillation prior to patent foramen ovale closure after cryptogenic stroke

BACKGROUND

Patients who had a cryptogenic stroke (CS) suspected to be causally related to a patent foramen ovale (PFO) are candidates for percutaneous PFO closure. In such patients, it is important to screen for atrial fibrillation (AF). Limited guidance is available regarding AF monitoring strategies in CS patients with PFO addressing optimal monitoring technology and duration.

AIM

To provide a narrative review of cardiac rhythm monitoring in CS patients considered for PFO closure, including current practices, stroke recurrences after CS, findings from monitoring studies in CS patients, and predictors for AF detection published in the literature. To propose a personalized strategy for cardiac monitoring in CS patients, accounting for aspects predicting AF detection.

SUMMARY OF REVIEW

AF detection in CS patients is predicted by age, left atrial enlargement, prolonged PR interval, frequent premature atrial contractions, interatrial conduction block, diabetes, prior brain infarctions, leukoaraiosis, elevated B-type natriuretic peptide (BNP)/N-terminal pro B-type natriuretic peptide (NT-proBNP) levels, and a family history of AF, as well as composed scores (e.g. CHA₂DS₂-VASc, atrial fibrillation in embolic stroke of undetermined source (AF-ESUS)). The causal role of the PFO may be accounted for by the risk of paradoxical embolism (RoPE) score and/or the PFO-Associated Stroke Causal Likelihood (PASCAL) classification.

CONCLUSION

A personalized approach to AF detection in CS patients is proposed, accounting for the likelihood of AF detection and aimed at obtaining sufficient confidence regarding the absence of AF in patients considered for PFO closure. In addition, the impact of high-risk PFO features on the monitoring strategy is discussed.

Novel Technologies in the Detection of Atrial Fibrillation: Review of Literature and Comparison of Different Novel Technologies for Screening of Atrial Fibrillation

Atrial fibrillation (AF) is globally the most common arrhythmia associated with significant morbidity and mortality. It impairs the quality of the patient's life, imposing a remarkable burden on public health, and the healthcare budget. The detection of AF is important in the decision to initiate anticoagulation therapy to prevent thromboembolic events. Nonetheless, AF detection is still a major clinical challenge as AF is often paroxysmal and asymptomatic. AF screening recommendations include opportunistic or systematic screening in patients ≥65 years of age or in those individuals with other characteristics pointing to an increased risk of stroke. The popularities of well-being and taking personal responsibility for one's own health are reflected in the continuous development and growth of mobile health technologies. These novel mobile health technologies could provide a cost-effective solution for AF screening and an additional opportunity to detect AF, particularly its paroxysmal and asymptomatic forms.

How often is occult atrial fibrillation in cryptogenic stroke causal vs. incidental? A meta-analysis

Introduction

Long-term cardiac monitoring studies have unveiled low-burden, occult atrial fibrillation (AF) in some patients with otherwise cryptogenic stroke (CS), but occult AF is also found in some individuals without a stroke history and in patients with stroke of a known cause (KS). Clinical management would be aided by estimates of how often occult AF in a patient with CS is causal vs. incidental.

Methods

Through a systematic search, we identified all case–control and cohort studies applying identical long-term monitoring techniques to both patients with CS and KS. We performed a random-effects meta-analysis across these studies to determine the best estimate of the differential frequency of occult AF in CS and KS among all patients and across age subgroups. We then applied Bayes' theorem to determine the probability that occult AF is causal or incidental.

Results

The systematic search identified three case–control and cohort studies enrolling 560 patients (315 CS, 245 KS). Methods of long-term monitoring were implantable loop recorder in 31.0%, extended external monitoring in 67.9%, and both in 1.2%. Crude cumulative rates of AF detection were CS 47/315 (14.9%) vs. KS 23/246 (9.3%). In the formal meta-analysis, the summary odds ratio for occult AF in CS vs. KS in all patients was 1.80 (95% CI, 1.05–3.07), p = 0.03. With the application of Bayes' theorem, the corresponding probabilities indicated that, when present, occult AF in patients with CS is causal in 38.2% (95% CI, 0–63.6%) of patients. Analyses stratified by age suggested that detected occult AF in patients with CS was causal in 62.3% (95 CI, 0–87.1%) of patients under the age of 65 years and 28.5% (95 CI, 0–63.7%) of patients aged 65 years and older but estimates had limited precision.

Conclusion

Current evidence is preliminary, but it indicates that in cryptogenic stroke when occult AF is found, it is causal in about 38.2% of patients. These findings suggest that anticoagulation therapy may be beneficial to prevent recurrent stroke in a substantial proportion of patients with CS found to have occult AF.

Protocol for a Systematic Review and Individual Participant Data Meta-Analysis of Randomized Trials of Screening for Atrial Fibrillation to Prevent Stroke

INTRODUCTION

 Atrial fibrillation (AF) is a common cause of stroke. Timely diagnosis of AF and treatment with oral anticoagulation (OAC) can prevent up to two-thirds of AF-related strokes. Ambulatory electrocardiographic (ECG) monitoring can identify undiagnosed AF in at-risk individuals, but the impact of population-based ECG screening on stroke is uncertain, as ongoing and published randomized controlled trials (RCTs) have generally been underpowered for stroke.

METHODS AND ANALYSIS

 The AF-SCREEN Collaboration, with support from AFFECT-EU, have begun a systematic review and individual participant data meta-analysis of RCTs evaluating ECG screening for AF. The primary outcome is stroke. Secondary outcomes include AF detection, OAC prescription, hospitalization, mortality, and bleeding.After developing a common data dictionary, anonymized data will be collated from individual trials into a central database. We will assess risk of bias using the Cochrane Collaboration tool, and overall quality of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach.We will pool data using random effects models. Prespecified subgroup and multilevel meta-regression analyses will explore heterogeneity. We will perform prespecified trial sequential meta-analyses of published trials to determine when the optimal information size has been reached, and account for unpublished trials using the SAMURAI approach.

IMPACT AND DISSEMINATION

 Individual participant data meta-analysis will generate adequate power to assess the risks and benefits of AF screening. Meta-regression will permit exploration of the specific patient, screening methodology, and health system factors that influence outcomes.

TRIAL REGISTRATION NUMBER

 PROSPERO CRD42022310308.

Patent Foramen Ovale and Cryptogenic Stroke: Integrated Management

Patent foramen ovale (PFO) is a common cardiac abnormality with a prevalence of 25% in the general population. PFO has been associated with the paradoxical embolism causing cryptogenic stroke and systemic embolization. Results from clinical trials, meta-analyses, and position papers support percutaneous PFO device closure (PPFOC), especially if interatrial septal aneurysms coexist and in the presence of large shunts in young patients. Remarkably, accurately evaluating patients to refer to the closure strategy is extremely important. However, the selection of patients for PFO closure is still not so clear. The aim of this review is to update and clarify which patients should be considered for closure treatment.

Insertable cardiac monitoring devices versus external cardiac monitoring for detecting atrial fibrillation and preventing the recurrence of stroke: A systematic review and meta-analysis

BACKGROUND

Atrial Fibrillation (AF) is a major risk factor for stroke, which is the second leading cause of death worldwide. It remains uncertain whether insertable cardiac monitors (ICMs) enhance the ability to recognize AF over external cardiac monitoring in patients who have experienced a stroke.

AIM

We conducted a systematic review and meta-analysis to determine whether ICM devices are more effective than external cardiac monitoring for the detection of AF in stroke patients.

METHODS

We included studies that reported an AF detection rate in stroke patients with a follow-up of at least 12 months. We analyzed the data of 1233 patients from 3 randomized control trials (RCTs).

RESULTS

When compared to external cardiac monitoring, ICM devices (Medtronic Reveal LINQ and Reveal XT) showed a significantly higher detection rate of AF (RR = 5.04, 95% CI = 2.93-8.68; p < 0.05; ARR = 10.47%, NNT = 10). The ICM arm had significantly higher usage of oral anticoagulants (OAC) as compared to the control arm. (RR = 2.76, 95% CI = 1.89-4.02, p < 0.05). Additionally, ICM usage was associated with a higher incidence of mild to moderate adverse events (RR = 10.52, 95% CI =1.35-82.14; p = 0.02) and a higher number of severe adverse events as compared to the control arm (RR = 7.61, 95% CI = 1.36-42.51; p = 0.02).

CONCLUSION

ICM devices are associated with better detection rates of AF and higher usage of OAC as compared to external cardiac monitoring in post-stroke patients. However, ICM insertion is associated with a higher incidence of mild/moderate and severe adverse effects.

A comparison of Atrial Fibrillation Detection Strategies After Ischemic Stroke-A Retrospective Study

Objective of this retrospective study was to determine if long-term continuous cardiac monitoring with Implantable loop recorder (ILR) in patients with Cryptogenic strokes or TIA is superior at detecting Atrial Fibrillation (AF) than 30-day Event Monitor (EM) and 48-hour Holter Monitor (HM). Furthermore, we aimed to deduce if uncovering AF leads to lower risk of future ischemic strokes, or reduction in mortality. In 20%-30% cases, the cause of stroke remained unexplained after diagnostic workup which has led to coining of the term, Cryptogenic Stroke (CS). Undiagnosed AF is a prime suspect in CS, but guidelines do not recommend initiation of anticoagulation unless AF has formally been detected. IRB approved retrospective study included patients with at least 1 episode of ischemic stroke or TIA without identifiable cause and was monitored with either HM, EM or ILR to diagnose any undiscovered AF. All patients (n = 531) had at least 1 year, and up to 3 years, of follow-up after device placement. Chi-Squared analysis and Multivariable logistic regression demonstrated no statistically significant difference among 3 devices for detection of AF within 1 month of index stroke but a significant difference in AF detection was observed at 6, 12 and 24 months. Cox proportional hazard model showed device type had no significant impact on secondary outcomes: Subsequent ischemic stroke or TIA, Initiation of anticoagulation, Mortality and Incidence of major bleeding. Despite the superiority of AF detection by ILR, it is not superior to HM or EM in lowering the risk of subsequent stroke or TIA, or in reducing mortality.

Immediate implantable loop recorder implantation for detecting atrial fibrillation in cryptogenic stroke

INTRODUCTION

Atrial fibrillation (AF) is suspected as the main cause of stroke in the majority of patients presenting with cryptogenic stroke (CS). Implantable loop recorders (ILR's) are indicated for detecting AF in these patients. The short term (<1 month) and long-term AF detection rates in patients inserted with an ILR immediately after CS is reported. Secondly, we compare the safety of nurse led vs physician led ILR implantation in these patients.

METHODS

This is a retrospective review of all patients who underwent inpatient ILR implantation (Medtronic Linq) between May 2020 and May 2022 at East Sussex Healthcare NHS trust. All patients were remotely monitored via the FOCUSON^TM monitoring and triage service.

RESULTS

A total of 186 subjects were included in the study and were followed up for a mean period of 363.0 +/- 222.6 days. The mean time between stroke and ILR was 7.0 +/- 5.5 days. The mean time between referral and ILR was 1.0 +/- 2.0 days. AF was detected in 25 (13.4%) patients. During the first 30 days of monitoring, AF was detected in 9 (4.8%) patients. The number of ILR implants performed by the specialist nurse was 107 (57.5%). There was no significant difference in the major complication rate (requiring device removal) between nurse and physician led implant (1 (0.95%) vs 0 (0%), p value = 0.389).

CONCLUSION

Inpatient ILR for cryptogenic stroke is feasible. The rate of AF detection in the first month post CS is 4.8% however, more AF was detected up to one year post implant, suggesting rationale for proceeding directly to ILR implant in these patients before discharge to not delay treatment. A nurse led service is also viable with no significant difference in the major complication rate compared to physician led implants.

Embolic Stroke of Undetermined Source: Current Perspectives on Diagnosis, Investigations, and Management

In 2014, Hart et al. introduced the concept of "embolic stroke of undetermined source" (ESUS) to the clinical-research stroke community. The hypothesis underlying the development of the ESUS construct was that this potentially heterogenous group of stroke mechanisms were largely thromboembolic, and would thus benefit from anticoagulation over antiplatelet for secondary prevention. Since then, 2 large clinical trials have shown that, to date, there is not a clear uniform antithrombotic strategy for secondary prevention after ESUS as it was originally broadly defined. However, this work has yielded valuable information about the patient phenotypes that experience ESUS strokes, as well as hypothesis-generating substudies that have given rise to the next generation of secondary prevention trials aimed at more personalized approaches for different suspected mechanisms of embolic stroke. In parallel with the evolution of ESUS, several studies aimed at screening for atrial fibrillation in the secondary stroke prevention population have generated additional questions about the mechanistic relevance of atrial fibrillation detected after stroke, and how this should inform poststroke workup, and secondary prevention strategies. Herein, we provide a synthesis of the current understanding surrounding the patient phenotypes that experience ESUS strokes, and previous, ongoing, and anticipated clinical trials that will guide earlier and later secondary prevention strategies and poststroke cardiac investigations.

Left atrial late gadolinium enhancement in patients with ischaemic stroke

AIMS

To evaluate the extent of left atrial (LA) fibrosis in patients with a recent stroke without atrial fibrillation and controls without established cardiovascular disease.

METHODS AND RESULTS

This prospectively designed study used cardiac magnetic resonance to detect LA late gadolinium enhancement as a proxy for LA fibrosis. Between 2019 and 2021, we consecutively included 100 patients free of atrial fibrillation with recent ischaemic stroke (<30 days) and 50 age- and sex-matched controls. LA fibrosis assessment was achieved in 78 patients and 45 controls. Blinded to the cardiac magnetic resonance results, strokes were adjudicated according to modified Trial of Org 10172 in Acute Stroke Treatment classification as undetermined aetiology (n = 42) or as attributable to large- or small-vessel disease (n = 36). Patients with stroke had a larger extent of LA fibrosis [6.9%, interquartile range (IQR) 3.6-15.4%] than matched controls (4.2%, IQR 2.3-7.5%; P = 0.007). No differences in LA fibrosis were observed between patients with stroke of undetermined aetiology and those with large- or small-vessel disease (6.6%, IQR 3.8-16.0% vs. 6.9%, IQR 3.4-14.6%; P = 0.73).

CONCLUSION

LA fibrosis was more extensive in patients with stroke than in age- and sex-matched controls. A similar extent of LA fibrosis was observed in patients with stroke of undetermined aetiology and stroke classified as attributable to large- or small-vessel disease. Our findings suggest that LA structural abnormality is more frequent in patients with stroke than in controls independent of aetiological classification.

Implantable loop recorders in patients with atrial fibrillation

INTRODUCTION

Implantable loop recorders (ILRs) provide practitioners with high-quality electrocardiographic data over an extended monitoring period. These data can guide the diagnosis and management of patients with atrial fibrillation (AF).

AREAS COVERED

This review summarizes the available evidence and consensus statements supporting the use of ILRs in the detection of AF, as well as monitoring of patients with known AF. Future directions for research are also discussed.

EXPERT OPINION

ILRs are the gold standard for detecting AF, providing superior diagnostic yield compared to other modes of ambulatory electrocardiography monitoring. Both experimental evidence and consensus statements support the use of ILRs in clinical settings where the diagnosis of AF may significantly change management, or where a high degree of sensitivity is needed. ILRs may also be used to monitor patients following AF ablation. More evidence is needed to better inform how ILR-detected AF should change management.

Clinical applications of heart rhythm monitoring tools in symptomatic patients and for screening in high-risk groups

Recent technological advances have facilitated and diversified the options available for the diagnosis of cardiac arrhythmias. Ranging from simple resting or exercise electrocardiograms to more sophisticated and expensive smartphones and implantable cardiac monitors. These tests and devices may be used for varying periods of time depending on symptom frequency. The choice of the most appropriate heart rhythm test should be guided by clinical evaluation and optimized following accurate characterization of underlying symptoms, 'red flags', risk factors, and consideration of cost-effectiveness of the different tests. This review provides evidence-based guidance for assessing suspected arrhythmia in patients who present with symptoms or in the context of screening, such as atrial fibrillation or advanced conduction disturbances following transcatheter aortic valve implantation in high-risk groups. This is intended to help clinicians choose the most appropriate diagnostic tool to facilitate the management of patients with suspected arrhythmias.

Prolonged cardiac monitoring for stroke prevention: A systematic review and meta-analysis of randomized-controlled clinical trials

Introduction:

Prolonged cardiac monitoring (PCM) substantially improves the detection of subclinical atrial fibrillation (AF) among patients with history of ischemic stroke (IS), leading to prompt initiation of anticoagulants. However, whether PCM may lead to IS prevention remains equivocal.

Patients and methods:

In this systematic review and meta-analysis, randomized-controlled clinical trials (RCTs) reporting IS rates among patients with known cardiovascular risk factors, including but not limited to history of IS, who received PCM for more than 7 days versus more conservative cardiac rhythm monitoring methods were pooled.

Results:

Seven RCTs were included comprising a total of 9048 patients with at least one known cardiovascular risk factor that underwent cardiac rhythm monitoring. PCM was associated with reduction of IS occurrence compared to conventional monitoring (Risk Ratio: 0.76; 95% CI: 0.59–0.96; I2 = 0%). This association was also significant in the subgroup of RCTs investigating implantable cardiac monitoring (Risk Ratio: 0.75; 95% CI: 0.58–0.97; I2 = 0%). However, when RCTs assessing PCM in both primary and secondary prevention settings were excluded or when RCTs investigating PCM with a duration of 7 days or less were included, the association between PCM and reduction of IS did not retain its statistical significance. Regarding the secondary outcomes, PCM was related to higher likelihood for AF detection and anticoagulant initiation. No association was documented between PCM and IS/transient ischemic attack occurrence, all-cause mortality, intracranial hemorrhage, or major bleeding.

Conclusion:

PCM may represent an effective stroke prevention strategy in selected patients. Additional RCTs are warranted to validate the robustness of the reported associations.

Monitoring and diagnosis of intermittent arrhythmias: evidence-based guidance and role of novel monitoring strategies

Technological advances have made diagnosis of heart rhythm disturbances much easier, with a wide variety of options, including single-lead portable devices, smartphones/watches to sophisticated implantable cardiac monitors, allowing accurate data to be collected over different time periods depending on symptoms frequency. This review provides an overview of the novel and existing heart rhythm testing options, including a description of the supporting evidence for their use. A description of each of the tests is provided, along with discussion of their advantages and limitations. This is intended to help clinicians towards choosing the most appropriate test, thus improving diagnostic yield management of patients with suspected arrhythmias.