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Santala OE, Lipponen JA, Jäntti H, Rissanen TT, Tarvainen MP, Väliaho ES, Rantula OA, Naukkarinen NS, Hartikainen JEK, Martikainen TJ, Halonen J. Novel Technologies in the Detection of Atrial Fibrillation: Review of Literature and Comparison of Different Novel Technologies for Screening of Atrial Fibrillation. Cardiol Rev 2024; 32:440-447. [PMID: 36946975 PMCID: PMC11296284 DOI: 10.1097/crd.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
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.
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Affiliation(s)
- Onni E. Santala
- From the School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Doctoral School, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jukka A. Lipponen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Helena Jäntti
- Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | | | - Mika P. Tarvainen
- Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
- Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Eemu-Samuli Väliaho
- From the School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Doctoral School, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Olli A. Rantula
- From the School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Doctoral School, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Noora S. Naukkarinen
- From the School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Doctoral School, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Juha E. K. Hartikainen
- From the School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | | | - Jari Halonen
- From the School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
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Chousou PA, Chattopadhyay RK, Matthews G, Clark A, Vassiliou VS, Pugh PJ. The incidence of atrial fibrillation detected by implantable loop recorders: a comparison between patients with and without embolic stroke of undetermined source. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae061. [PMID: 39219854 PMCID: PMC11366165 DOI: 10.1093/ehjopen/oeae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/12/2024] [Accepted: 07/19/2024] [Indexed: 09/04/2024]
Abstract
Aims Stroke is the most debilitating outcome of atrial fibrillation (AF). The use of implantable loop recorders increases the detection of AF episodes among patients with embolic stroke of undetermined source. The significance of device-detected AF, or subclinical AF, is unknown. This study aimed to compare the incidence of AF detected by implantable loop recorder in patients with and without embolic stroke of undetermined source. Methods and results We retrospectively studied all patients without known AF who were referred to our institution for implantable loop recorder implantation following embolic stroke of undetermined source, syncope, or palpitations from March 2009 to November 2019. The primary endpoint was any detection of AF or atrial flutter by implantable loop recorder. Seven hundred and fifty patients were included and followed up for a mean duration of 731 days (SD 443). An implantable loop recorder was implanted following embolic stroke of undetermined source in 323 and for assessment of syncope, palpitations, or another reason in 427 patients. The incidence of AF was significantly (P < 0.001) higher among patients with embolic stroke of undetermined source compared with the non-embolic stroke of undetermined source group; 48.6% vs. 13.8% (for any duration of AF) and 32.2% vs. 12.4% (for AF lasting ≥30 s) both P < 0.001. Kaplan-Meier analysis showed significantly higher incidence of AF for incremental durations of AF up to >5.5 h, but not >24 h. This was driven by longest AF durations of <6 min and between 5.5 h and 24 h, suggesting a bimodal distribution. In a multivariable Cox regression analysis, embolic stroke of undetermined source independently conferred an almost 5-fold increase in the hazard for any duration of AF. Conclusion The incidence of AF is significantly higher amongst embolic stroke of undetermined source vs. non-embolic stroke of undetermined source patients monitored constantly by an implantable loop recorder. A high number of embolic stroke of undetermined source survivors have short-duration AF episodes. Further work is needed to determine the optimal treatment strategy of these AF episodes in embolic stroke of undetermined source.
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Affiliation(s)
- Panagiota A Chousou
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
- Department of Cardiology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hill's Road, Cambridge CB2 0QQ, UK
| | - Rahul K Chattopadhyay
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
- Department of Cardiology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hill's Road, Cambridge CB2 0QQ, UK
| | - Gareth Matthews
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
- Department of Cardiology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
| | - Vassilios S Vassiliou
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
- Department of Cardiology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Peter J Pugh
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
- Department of Cardiology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hill's Road, Cambridge CB2 0QQ, UK
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McIntyre WF, Benz AP, Tojaga N, Brandes A, Lopes RD, Healey JS. Direct oral anticoagulants for stroke prevention in patients with device-detected atrial fibrillation: assessing net clinical benefit. Eur Heart J Suppl 2024; 26:iv4-iv11. [PMID: 39099575 PMCID: PMC11292410 DOI: 10.1093/eurheartjsupp/suae075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
Subclinical, device-detected atrial fibrillation (AF) is frequently recorded by pacemakers and other implanted cardiac rhythm devices. Patients with device-detected AF have an elevated risk of stroke, but a lower risk of stroke than similar patients with clinical AF captured with surface electrocardiogram. Two randomized clinical trials (NOAH-AFNET 6 and ARTESiA) have tested a direct oral anticoagulant (DOAC) against aspirin or placebo. A study-level meta-analysis of the two trials found that treatment with a DOAC resulted in a 32% reduction in ischaemic stroke and a 62% increase in major bleeding; the results of the two trials were consistent. The annualized rate of stroke in the control arms was ∼1%. Several factors point towards overall net benefit from DOAC treatment for patients with device-detected AF. Strokes in ARTESiA were frequently fatal or disabling and bleeds were rarely lethal. The higher absolute rates of major bleeding compared with ischaemic stroke while on treatment with a DOAC in the two trials are consistent with the ratio of bleeds to strokes seen in the pivotal DOAC vs. warfarin trials in patients with clinical AF. Prior research has concluded that patients place a higher emphasis on stroke prevention than on bleeding. Further research is needed to identify the characteristics that will help identify patients with device-detected AF who will receive the greatest benefit from DOAC treatment.
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario, L8L 2X2, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario, L8L 2X2, Canada
- Department of Cardiology, University Medical Centre Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Nedim Tojaga
- Department of Cardiology, Esbjerg and Grindsted Hospital—University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Axel Brandes
- Department of Cardiology, Esbjerg and Grindsted Hospital—University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 237 Barton St East, Hamilton, Ontario, L8L 2X2, Canada
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4
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Sposato LA, Field TS, Schnabel RB, Wachter R, Andrade JG, Hill MD. Towards a new classification of atrial fibrillation detected after a stroke or a transient ischaemic attack. Lancet Neurol 2024; 23:110-122. [PMID: 37839436 DOI: 10.1016/s1474-4422(23)00326-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/03/2023] [Accepted: 08/21/2023] [Indexed: 10/17/2023]
Abstract
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.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Heart and Brain Laboratory, Western University, London, ON, Canada; Robarts Research Institute, Western University, London, ON, Canada; Lawson Health Research Institute, London, ON, Canada.
| | - Thalia S Field
- Division of Neurology, Vancouver Stroke Program, University of British Columbia, Vancouver, BC, Canada
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany; Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany; German Cardiovascular Research Centre, Partner site Göttingen, Göttingen, Germany
| | - Jason G Andrade
- Division of Cardiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Center for Cardiovascular Innovation, Vancouver, BC, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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5
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Reiffel JA. Selected Advances in the Anti-arrhythmic Management of Atrial Fibrillation: 2023. J Innov Card Rhythm Manag 2024; 15:5728-5734. [PMID: 38304092 PMCID: PMC10829416 DOI: 10.19102/icrm.2024.15014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
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Yetkin E, Atmaca H, Cuglan B, Yalta K. Ignored Role of Paroxysmal Atrial Fibrillation in the Pathophysiology of Cryptogenic Stroke in Patients with Patent Foramen Ovale and Atrial Septal Aneurysm. Curr Cardiol Rev 2024; 20:14-19. [PMID: 38367262 PMCID: PMC11107473 DOI: 10.2174/011573403x267669240125041203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/17/2023] [Accepted: 11/23/2023] [Indexed: 02/19/2024] Open
Abstract
The association between cryptogenic stroke (CS) and patent foramen ovale (PFO) with or without atrial septal aneurysm (ASA) has been a debate for decades in terms of pathophysiologic processes and clinical courses. This issue has become more interesting and complex, because of the concerns associating the CS with so-called normal variant pathologies of interatrial septum, namely ASA and PFO. While there is an anatomical pathology in the interatrial septum, namely PFO and ASA, the embolic source of stroke is not clearly defined. Moreover, in patients with PFO and CS, the risk of recurrent stroke has also been associated with other PFOunrelated factors, such as hyperlipidemia, body mass index, diabetes mellitus, and hypertension, leading to the difficulty in understanding the pathophysiologic mechanism of CS in patients with PFO and/or ASA. Theoretically, the embolic source of cryptogenic stroke in which PFO and/or ASA has been involved can be categorized into three different anatomical locations, namely PFO tissue and/or ASA tissue itself, right or left atrial chambers, and venous vascular territory distal to the right atrium, i.e., inferior vena cava and lower extremity venous system. However, the possible role of paroxysmal atrial fibrillation associated with PFO and/or ASA as a source of cryptogenic stroke has never been mentioned clearly in the literature. This review aims to explain the association of cryptogenic stroke with PFO and/or ASA in a comprehensive manner, including anatomical, clinical, and mechanistic aspects. The potential role of paroxysmal atrial fibrillation and its contribution to clinical course have been also discussed in a hypothetical manner to elucidate the pathophysiology of CS and support further treatment modalities.
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Affiliation(s)
- Ertan Yetkin
- Division of Cardiology, Türkiye Hospital, Istanbul, Turkey
| | - Hasan Atmaca
- Division of Cardiology, Türkiye Hospital, Istanbul, Turkey
| | - Bilal Cuglan
- Department of Cardiology, Kanuni Sultan Suleiman Training and Research Hospital, Istanbul, Turkey
| | - Kenan Yalta
- Department of Cardiology, Faculty of Medicine Edirne, Trakya University, Trakya, Turkey
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7
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Razina TV, Serova MV, Andreev DA, Sazonova YS, Komarova AG. [Tactics of anticoagulant therapy in patients with cardiac implantable electronic devices and subclinical atrial fibrillation: A review]. TERAPEVT ARKH 2023; 95:472054. [PMID: 38158984 DOI: 10.26442/00403660.2023.04.202189] [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] [Received: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 01/03/2024]
Abstract
Screening for atrial fibrillation (AF) has attracted considerable attention recently. Of special interest are patients with cardiac implantable electronic devices (CIEDs) that allow for recording episodes of atrial arrhythmias of various durations, including asymptomatic ones, in which case they are referred to as subclinical atrial fibrillation (SCAF). The available data suggest that the risk of thromboembolic events varies between patients with SCAF and clinically overt AF. As of today, the question regarding anticoagulant therapy in patients with SCAF remains unresolved. The article presents an overview of previous and ongoing studies on this issue, as well as current guidelines on anticoagulant use in patients with SCAF and CIEDs.
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Affiliation(s)
- T V Razina
- Sechenov First Moscow State Medical University (Sechenov University)
| | - M V Serova
- Sechenov First Moscow State Medical University (Sechenov University)
- Pirogov City Clinical Hospital №1 Moscow
| | - D A Andreev
- Sechenov First Moscow State Medical University (Sechenov University)
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8
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Elkind MSV, Witte KK, Kasner SE, Sawyer LM, Grimsey Jones FW, Rinciog C, Tsintzos S, Rosemas SC, Lanctin D, Ziegler PD, Reynolds MR. Cost-effectiveness of an insertable cardiac monitor in a high-risk population in the US. BMC Cardiovasc Disord 2023; 23:45. [PMID: 36698055 PMCID: PMC9875401 DOI: 10.1186/s12872-023-03073-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Insertable cardiac monitors (ICMs) are a clinically effective means of detecting atrial fibrillation (AF) in high-risk patients, and guiding the initiation of non-vitamin K oral anticoagulants (NOACs). Their cost-effectiveness from a US clinical payer perspective is not yet known. The objective of this study was to evaluate the cost-effectiveness of ICMs compared to standard of care (SoC) for detecting AF in patients at high risk of stroke (CHADS2 ≥ 2), in the US. METHODS Using patient data from the REVEAL AF trial (n = 393, average CHADS2 score = 2.9), a Markov model estimated the lifetime costs and benefits of detecting AF with an ICM or with SoC (specifically intermittent use of electrocardiograms and 24-h Holter monitors). Ischemic and hemorrhagic strokes, intra- and extra-cranial hemorrhages, and minor bleeds were modelled. Diagnostic and device costs, costs of treating stroke and bleeding events and medical therapy-specifically costs of NOACs were included. Costs and health outcomes, measured as quality-adjusted life years (QALYs), were discounted at 3% per annum, in line with standard practice in the US setting. One-way deterministic and probabilistic sensitivity analyses (PSA) were undertaken. RESULTS Lifetime per-patient cost for ICM was $31,116 versus $25,330 for SoC. ICMs generated a total of 7.75 QALYs versus 7.59 for SoC, with 34 fewer strokes projected per 1000 patients. The model estimates a number needed to treat of 29 per stroke avoided. The incremental cost-effectiveness ratio was $35,528 per QALY gained. ICMs were cost-effective in 75% of PSA simulations, using a $50,000 per QALY threshold, and a 100% probability of being cost-effective at a WTP threshold of $150,000 per QALY. CONCLUSIONS The use of ICMs to identify AF in a high-risk population is likely to be cost-effective in the US healthcare setting.
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Affiliation(s)
- Mitchell S. V. Elkind
- grid.21729.3f0000000419368729Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY USA
| | - Klaus K. Witte
- grid.9909.90000 0004 1936 8403Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK ,grid.412301.50000 0000 8653 1507University Clinic, RWTH, Aachen, Germany
| | - Scott E. Kasner
- grid.25879.310000 0004 1936 8972Department of Neurology, University of Pennsylvania, Philadelphia, PA USA
| | | | | | | | | | | | - David Lanctin
- grid.419673.e0000 0000 9545 2456Medtronic, Mounds View, MN USA
| | - Paul D. Ziegler
- grid.419673.e0000 0000 9545 2456Medtronic, Mounds View, MN USA
| | - Matthew R. Reynolds
- grid.488688.20000 0004 0422 1863Baim Institute for Clinical Research, Boston, MA USA ,grid.415731.50000 0001 0725 1353Lahey Hospital and Medical Center, Burlington, MA USA
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Sharma AN, McIntyre WF, Nguyen ST, Baranchuk A. Implantable loop recorders in patients with atrial fibrillation. Expert Rev Cardiovasc Ther 2022; 20:919-928. [PMID: 36444859 DOI: 10.1080/14779072.2022.2153673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Arjun N Sharma
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, ON, Canada
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10
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Brandes A, Stavrakis S, Freedman B, Antoniou S, Boriani G, Camm AJ, Chow CK, Ding E, Engdahl J, Gibson MM, Golovchiner G, Glotzer T, Guo Y, Healey JS, Hills MT, Johnson L, Lip GYH, Lobban T, Macfarlane PW, Marcus GM, McManus DD, Neubeck L, Orchard J, Perez MV, Schnabel RB, Smyth B, Steinhubl S, Turakhia MP. Consumer-Led Screening for Atrial Fibrillation: Frontier Review of the AF-SCREEN International Collaboration. Circulation 2022; 146:1461-1474. [PMID: 36343103 PMCID: PMC9673231 DOI: 10.1161/circulationaha.121.058911] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/22/2022] [Indexed: 11/09/2022]
Abstract
The technological evolution and widespread availability of wearables and handheld ECG devices capable of screening for atrial fibrillation (AF), and their promotion directly to consumers, has focused attention of health care professionals and patient organizations on consumer-led AF screening. In this Frontiers review, members of the AF-SCREEN International Collaboration provide a critical appraisal of this rapidly evolving field to increase awareness of the complexities and uncertainties surrounding consumer-led AF screening. Although there are numerous commercially available devices directly marketed to consumers for AF monitoring and identification of unrecognized AF, health care professional-led randomized controlled studies using multiple ECG recordings or continuous ECG monitoring to detect AF have failed to demonstrate a significant reduction in stroke. Although it remains uncertain if consumer-led AF screening reduces stroke, it could increase early diagnosis of AF and facilitate an integrated approach, including appropriate anticoagulation, rate or rhythm management, and risk factor modification to reduce complications. Companies marketing AF screening devices should report the accuracy and performance of their products in high- and low-risk populations and avoid claims about clinical outcomes unless improvement is demonstrated in randomized clinical trials. Generally, the diagnostic yield of AF screening increases with the number, duration, and temporal dispersion of screening sessions, but the prognostic importance may be less than for AF detected by single-time point screening, which is largely permanent, persistent, or high-burden paroxysmal AF. Consumer-initiated ECG recordings suggesting possible AF always require confirmation by a health care professional experienced in ECG reading, whereas suspicion of AF on the basis of photoplethysmography must be confirmed with an ECG. Consumer-led AF screening is unlikely to be cost-effective for stroke prevention in the predominantly young, early adopters of this technology. Studies in older people at higher stroke risk are required to demonstrate both effectiveness and cost-effectiveness. The direct interaction between companies and consumers creates new regulatory gaps in relation to data privacy and the registration of consumer apps and devices. Although several barriers for optimal use of consumer-led screening exist, results of large, ongoing trials, powered to detect clinical outcomes, are required before health care professionals should support widespread adoption of consumer-led AF screening.
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Affiliation(s)
| | - Stavros Stavrakis
- Cardiovascular Section, University of Oklahoma Health Science Center
| | - Ben Freedman
- Heart Research Institute, University of Sydney, Sydney, Australia
| | | | - Giuseppe Boriani
- Department of Cardiology, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Clara K. Chow
- Cardiovascular Division, University of Sydney, Sydney, Australia
| | - Eric Ding
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Johan Engdahl
- Department of Cardiology, Karolinska Institute, Stockholm, Sweeden
| | - Michael M. Gibson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Taya Glotzer
- Hackensack University Medical Center, Hackensack, NJ
| | - Yutao Guo
- Chinese PLA General Hospital, Beijing, China
| | | | | | | | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | | | | | - Gregory M. Marcus
- Department of Cardiology, University of California, San Francisco, San Franscisco, CA
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Lis Neubeck
- Centre for Cardiovascular Health, Edinburgh Napier University
| | - Jessica Orchard
- Charles Perkins Centre, University of Sydney, Sydney, Australia
| | | | | | - Breda Smyth
- Department of Public Health, Health Service Executive West, Galway, Ireland
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11
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Kreimer F, Mügge A, Gotzmann M. How should I treat patients with subclinical atrial fibrillation and atrial high-rate episodes? Current evidence and clinical importance. Clin Res Cardiol 2022; 111:994-1009. [PMID: 35292844 PMCID: PMC9424173 DOI: 10.1007/s00392-022-02000-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/01/2022] [Indexed: 11/28/2022]
Abstract
Long-term and continuous ECG monitoring using cardiac implantable electronic devices and insertable cardiac monitors has improved the capability of detecting subclinical atrial fibrillation (AF) and atrial high-rate episodes. Previous studies demonstrated a high prevalence (more than 20%) in patients with cardiac implantable electronic devices or insertable cardiac monitors. Subclinical AF and atrial high-rate episodes are often suspected as the cause of prior or potential future ischemic stroke. However, the clinical significance is still uncertain, and the evidence is limited. This review aims to present and discuss the current evidence on the clinical impact of subclinical AF and atrial high-rate episodes. It focuses particularly on the association between the duration of the episodes and major clinical outcomes like thromboembolic events. As subclinical AF and atrial high-rate episodes are presumed to be associated with ischemic strokes, detection will be particularly important in patients with cryptogenic stroke and in high-risk patients for thromboembolism. In this context, it is also interesting whether there is a temporal relationship between the detection of subclinical AF and atrial high-rate episodes and the occurrence of thromboembolic events. In addition, the review will examine the question whether there is a need for a therapy with oral anticoagulation.
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Affiliation(s)
- Fabienne Kreimer
- University Hospital St Josef-Hospital Bochum, Cardiology and Rhythmology, Ruhr University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Andreas Mügge
- University Hospital St Josef-Hospital Bochum, Cardiology and Rhythmology, Ruhr University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Michael Gotzmann
- University Hospital St Josef-Hospital Bochum, Cardiology and Rhythmology, Ruhr University Bochum, Gudrunstraße 56, 44791, Bochum, Germany.
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McIntyre WF, Wang J, Benz AP, Johnson L, Connolly SJ, Van Gelder IC, Lopes RD, Gold MR, Hohnloser SH, Lau CP, Israel CW, Wong JA, Conen D, Healey JS. Estimated incidence of previously undetected atrial fibrillation on a 14-day continuous electrocardiographic monitor and associated risk of stroke. Europace 2022; 24:1058-1064. [DOI: 10.1093/europace/euab324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
There is uncertainty about whether and how to perform screening for atrial fibrillation (AF). To estimate the incidence of previously undetected AF that would be captured using a continuous 14-day ECG monitor and the associated risk of stroke.
Methods and results
We analysed data from a cohort of patients >65 years old with hypertension and a pacemaker, but without known AF. For each participant, we simulated 1000 ECG monitors by randomly selecting 14-day windows in the 6 months following enrolment and calculated the average AF burden (total time in AF). We used Cox proportional hazards models adjusted for CHA2DS2-VASc score to estimate the risk of subsequent ischaemic stroke or systemic embolism (SSE) associated with burdens of AF > and <6 min. Among 2470 participants, the median CHA2DS2-VASc score was 4.0, and 44 patients experienced SSE after 6 months following enrolment. The proportion of participants with an AF burden >6 min was 3.10% (95% CI 2.53–3.72). This was consistent across strata of age and CHA2DS2-VASc scores. Over a mean follow-up of 2.4 years, the rate of SSE among patients with <6 min of AF was 0.70%/year, compared to 2.18%/year (adjusted HR 3.02; 95% CI 1.39–6.56) in those with >6 min of AF.
Conclusions
Approximately 3% of individuals aged >65 years with hypertension may have more than 6 min of AF detected by a 14-day ECG monitor. This is associated with a stroke risk of over 2% per year. Whether oral anticoagulation will reduce stroke in these patients is unknown.
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jia Wang
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
| | - Alexander P Benz
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
| | - Linda Johnson
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
| | - Stuart J Connolly
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, NC, USA
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Stefan H Hohnloser
- Department of Electrophysiology, J.W. Goetshe University, Frankfurt, Germany
| | - Chu-Pak Lau
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Carsten W Israel
- Division of Cardiology, Department of Medicine, Evangelical Hospital Bielefeld, Bielefeld, Germany
| | - Jorge A Wong
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David Conen
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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13
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Özge G, Kepez A, Uğur K, Görenek B. What to do with device-detected atrial high-rate episodes: Summary of the evidences. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:250-261. [PMID: 34927268 DOI: 10.1111/pace.14428] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/17/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022]
Abstract
Cardiac implanted electronic devices (CIEDs), that perform atrial sensing via an atrial electrode, commonly detect self-terminating atrial arrhythmias. Nomenclature of these arrhythmias is defined as atrial high-rate episodes (AHREs) and subclinical atrial fibrillation (SCAF). We have provided a comprehensive summation of the trials regarding the incidence and adverse outcomes of AHREs. The reported incidence of AHRE varies considerably (approximately 10% to %70) between studies depending on the definition of AHRE, duration of follow-up and the clinical profile of the population. There is increasing evidence related with the association between AHREs' and stroke and/or systemic embolism. However, risk of stroke and/or systemic embolism seems to be less than the risk associated with clinical AF. There is still lack of sufficient evidence related with oral anticoagulation (OAC) in patients with AHRE to reduce thromboembolic risk. Although, the strongest association of OAC treatment with reduction in stroke has been reported to be observed among patients with device detected SCAF episodes of >24 hours; it is still questionable whether AHRE is a direct cause of thromboembolic event or just a marker of increased risk. Results of ongoing randomized clinical trials (NOAH-AFNET 6 and ARTESIA) will provide robust evidence on effect of OAC therapy on AHREs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Gurbet Özge
- Eskişehir Osmangazi University, Faculty of Medicine, Department of Cardiology, Eskişehir, Turkey
| | - Alper Kepez
- Marmara University, Faculty of Medicine, Department of Cardiology, İstanbul, Turkey
| | - Kadir Uğur
- Eskişehir Osmangazi University, Faculty of Medicine, Department of Cardiology, Eskişehir, Turkey
| | - Bülent Görenek
- Eskişehir Osmangazi University, Faculty of Medicine, Department of Cardiology, Eskişehir, Turkey
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14
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Philippsen TJ, Christensen LS, Nybo M, Hansen MS, Dahl JS, Brandes A. Circulating biomarkers, echocardiographic parameters, and incident subclinical atrial fibrillation in patients with diabetes and hypertension. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:35-42. [PMID: 34739729 DOI: 10.1111/pace.14399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/23/2021] [Accepted: 10/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Long-term rhythm monitoring (LTRM) can detect undiagnosed atrial fibrillation (AF) in patients at high risk of AF and stroke. Biomarkers and echocardiographic parameters could, however, help identify patients benefitting most from LTRM. The aim of this study was to investigate, whether circulating biomarkers of cardiac and vascular function (brain natriuretic peptide (BNP), cardiac troponin I (cTnI), copeptin, and mid-regional proadrenomedullin (MR-proADM)) and echocardiographic parameters were associated with incident subclinical AF (SCAF) in a population at high risk of stroke in the presence of AF. For this purpose, we investigated individuals ≥65 years of age with hypertension and diabetes mellitus, but no history or symptoms of AF or other cardiovascular disease (CVD). METHODS We included 82 consecutive patients (median age 71.3 years (IQR 67.4-75.1)). All patients received an insertable cardiac monitor (ICM) and were followed for a median of 588 days (IQR 453-712). On the day of ICM implantation, a comprehensive echocardiogram and blood samples were obtained. RESULTS During a median follow-up of 588 days (IQR: 453-712 days), incident SCAF occurred in 17 patients (20.7%) with a median time to first-detected episode of 91 days (IQR 41-251 days). MR-proADM (median 0.87 nmol/L (IQR 0.76-1.02) vs 0.78 nmol/L (IQR 0.68-0.98)) and copeptin (median 13 pmol/L (IQR 9-17) vs 8 pmol/L (IQR 4-18)) levels were insignificantly higher in patients with incident SCAF. BNP and cTnI concentrations and echocardiographic parameters were similar in the two groups. CONCLUSIONS MR-proADM, BNP, cTnI, copeptin, and several echocardiographic parameters were not associated with incident SCAF in this cohort of patients with hypertension and diabetes, but without any underlying CVD.
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Affiliation(s)
- Tine J Philippsen
- Department of Cardiology, Hospital of Southern Jutland, Aabenraa, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark.,OPEN - Open Patient Data Explorative Network, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Lene S Christensen
- Department of Cardiology, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Michael S Hansen
- Department of Cardiology, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Internal Medicine - Cardiology, University Hospital of Southern Denmark, Esbjerg, Denmark
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15
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Roten L, Goulouti E, Lam A, Elchinova E, Nozica N, Spirito A, Wittmer S, Branca M, Servatius H, Noti F, Seiler J, Baldinger SH, Haeberlin A, de Marchi S, Asatryan B, Rodondi N, Donzé J, Aujesky D, Tanner H, Reichlin T, Jüni P. Age and Sex Specific Prevalence of Clinical and Screen-Detected Atrial Fibrillation in Hospitalized Patients. J Clin Med 2021; 10:4871. [PMID: 34768391 PMCID: PMC8584962 DOI: 10.3390/jcm10214871] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/13/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The prevalence of atrial fibrillation (AF) is high in older patients. The present study aimed to estimate the age and sex specific prevalence of clinical and screen-detected atrial fibrillation (AF) in hospitalized patients. METHODS The STAR-FIB cohort study was a prospective cohort study recruiting participants from a large source population of hospitalized patients aged 65-84 years. The estimated size of the source population was 26,035 (95% CI 25,918-26,152), and 795 consenting patients without clinical AF were included in the cohort study after stratification by sex and age (49.2% females; mean age 74.7 years). Patients in the cohort study underwent three seven-day Holter ECGs in intervals of two months to screen for AF. RESULTS In the source population, the estimated prevalence of clinical AF was 22.2% (95% CI 18.4-26.1), 23.8% for males (95% CI 20.9-26.6) and 19.8% for females (95% CI 17.3-22.4; p for difference between sexes, 0.004). There was a linear trend for an increase in the prevalence of clinical AF with increasing age, overall and in both sexes. In the cohort study, AF was newly diagnosed in 38 patients, for an estimated prevalence of screen-detected AF of 4.9% overall (95% CI 3.3-6.6), 5.5% in males (95% CI 3.2-7.8) and 4.0% in females (95% CI 2.0-6.0; p for difference between sexes, 0.041). The estimated prevalence of screen-detected AF in the source population was 3.8% overall, 4.2% in males and 3.2% in females. CONCLUSION In a large hospital-based patient population aged 65-84 years, the prevalence of clinical AF and of screen-detected AF was 22.2% and 3.8%, respectively, and significantly higher in males than females.
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Affiliation(s)
- Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Eleni Goulouti
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Anna Lam
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Elena Elchinova
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Nikolas Nozica
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Alessandro Spirito
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Severin Wittmer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Mattia Branca
- Clinical Trials Unit, University of Bern, 3012 Bern, Switzerland;
| | - Helge Servatius
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Fabian Noti
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Jens Seiler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Samuel H Baldinger
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
- Sitem Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, 3010 Bern, Switzerland
| | - Stefano de Marchi
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Babken Asatryan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (N.R.); (D.A.)
- Institute of Primary Health Care (BIHAM), University of Bern, 3012 Bern, Switzerland
| | - Jacques Donzé
- Department of Medicine, Neuchâtel Hospital Network, 2000 Neuchâtel, Switzerland;
- Department of Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (N.R.); (D.A.)
| | - Hildegard Tanner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (E.G.); (A.L.); (E.E.); (N.N.); (A.S.); (S.W.); (H.S.); (F.N.); (J.S.); (S.H.B.); (A.H.); (S.d.M.); (B.A.); (H.T.); (T.R.)
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine, University of Toronto, Toronto, ON M5S, Canada;
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16
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Elkind MSV, Wachter R, Verma A, Kowey PR, Halperin JL, Gersh BJ, Ziegler PD, Pouliot E, Franco N, Reiffel JA. Use of the HAVOC Score to Identify Patients at Highest Risk of Developing Atrial Fibrillation. Cardiology 2021; 146:633-640. [PMID: 34157712 DOI: 10.1159/000517827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 06/13/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Mitchell S V Elkind
- Departments of Neurology and Epidemiology, Columbia University, New York, New York, USA
| | - Rolf Wachter
- University Hospital Leipzig, Leipzig, Germany
- University Medicine Göttingen and German Cardiovascular Research Center, Göttingen, Germany
| | - Atul Verma
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | - Peter R Kowey
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
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17
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Wachter R, Freedman B. Subclinical Atrial Fibrillation and the Risk of Recurrent Ischemic Stroke. Thromb Haemost 2021; 121:697-699. [PMID: 34020463 DOI: 10.1055/s-0041-1726403] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany.,German Cardiovascular Research Center, partner site Göttingen, Göttingen, Germany
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, University of Sydney, Camperdown, Sydney, NSW, Australia.,Department of Cardiology, Concord Hospital, Hospital Road, Concord, NSW, Australia
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18
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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19
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Boriani G, Vitolo M, Diemberger I, Proietti M, Valenti AC, Malavasi VL, Lip GYH. Optimizing indices of AF susceptibility and burden to evaluate AF severity, risk and outcomes. Cardiovasc Res 2021; 117:1-21. [PMID: 33913486 PMCID: PMC8707734 DOI: 10.1093/cvr/cvab147] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/15/2021] [Accepted: 04/29/2021] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) has heterogeneous patterns of presentation concerning symptoms,
duration of episodes, AF burden, and the tendency to progress towards the terminal step of
permanent AF. AF is associated with a risk of stroke/thromboembolism traditionally
considered dependent on patient-level risk factors rather than AF type, AF burden, or
other characterizations. However, the time spent in AF appears related to an incremental
risk of stroke, as suggested by the higher risk of stroke in patients with clinical AF vs.
subclinical episodes and in patients with non-paroxysmal AF vs. paroxysmal AF. In patients
with device-detected atrial tachyarrhythmias, AF burden is a dynamic process with
potential transitions from a lower to a higher maximum daily arrhythmia burden, thus
justifying monitoring its temporal evolution. In clinical terms, the appearance of the
first episode of AF, the characterization of the arrhythmia in a specific AF type, the
progression of AF, and the response to rhythm control therapies, as well as the clinical
outcomes, are all conditioned by underlying heart disease, risk factors, and
comorbidities. Improved understanding is needed on how to monitor and modulate the effect
of factors that condition AF susceptibility and modulate AF-associated outcomes. The
increasing use of wearables and apps in practice and clinical research may be useful to
predict and quantify AF burden and assess AF susceptibility at the individual patient
level. This may help us reveal why AF stops and starts again, or why AF episodes, or
burden, cluster. Additionally, whether the distribution of burden is associated with
variations in the propensity to thrombosis or other clinical adverse events. Combining the
improved methods for data analysis, clinical and translational science could be the basis
for the early identification of the subset of patients at risk of progressing to a longer
duration/higher burden of AF and the associated adverse outcomes.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinico Scientifici Maugeri, Milan, Italy
| | - Anna Chiara Valenti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Vincenzo Livio Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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20
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Reiffel JA, Verma A, Kowey PR, Halperin JL, Gersh BJ, Wachter R, Elkind MSV, Pouliot E, Ziegler PD. Relation of Antecedent Symptoms to the Likelihood of Detecting Subclinical Atrial Fibrillation With Inserted Cardiac Monitors. Am J Cardiol 2021; 145:64-68. [PMID: 33497655 DOI: 10.1016/j.amjcard.2020.12.083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 01/27/2023]
Abstract
Atrial fibrillation (AF) comes to attention clinically during an evaluation of symptoms, an evaluation of its adverse outcomes, or because of incidental detection during a routine examination or electrocardiogram. However, a notable number of additional individuals have AF that has not yet been clinically apparent or suspect-subclinical AF (SCAF). SCAF has been recognized during interrogation of pacemakers and defibrillators. More recently, SCAF has been demonstrated in prospective studies with long-term monitors-both external and implanted. The REVEAL AF trial enrolled a demographically "enriched" population that underwent monitoring for up to 3 years with an insertable cardiac monitor. SCAF was noted in 40% by 30 months. None of these patients had AF known before the study; however, some had nonspecific symptoms common to patients with known AF. The current study assessed whether patients with versus without such symptoms were more likely to have SCAF detected. We found that only palpitations had an association with AF detection when controlling for other baseline symptoms (hazard ratio 1.61 (95% confidence interval 1.12 to 2.32; p = 0.011). No other prescreening symptoms evaluated were associated with an increased likelihood of SCAF detection although patients without detected SCAF had an even higher frequency of symptoms than those with detected SCAF. Thus, REVEAL AF demonstrated that the presence of palpitations is associated with an increased likelihood of SCAF whereas other common symptoms are not; and, symptoms, per se, may more likely be consequent to associated disorders than they are a direct consequence of SCAF.
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Affiliation(s)
- James A Reiffel
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York City, New York.
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, University of Toronto, Toronto, Ontario, Canada
| | - Peter R Kowey
- Lankenau Institute for Medical Research, Wynnewood, PA, and, the Jefferson Medical College, Philadelphia, Pennsylvania
| | - Jonathan L Halperin
- The Cardiovascular Institute, Mount Sinai Medical Center, New York City, New York
| | | | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physician & Surgeons, Columbia University, New York City, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, New York
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21
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5483] [Impact Index Per Article: 1827.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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22
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Atrial fibrillation and stroke: how much atrial fibrillation is enough to cause a stroke? Curr Opin Neurol 2021; 33:17-23. [PMID: 31809335 DOI: 10.1097/wco.0000000000000780] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW The association between atrial fibrillation and stroke is firmly established, and anticoagulation reduces stroke risk in patients with atrial fibrillation. However, the role of anticoagulation in very brief durations of atrial fibrillation (subclinical atrial fibrillation) is an area of controversy. RECENT FINDINGS Stroke risk increases alongside burden of atrial fibrillation. Ongoing trials will clarify if 24 h or less of atrial fibrillation on extended monitoring necessitates lifelong anticoagulation. Trials examining empiric anticoagulation for individuals with ESUS did not demonstrate benefit over antiplatelet agents. However, hypothesis-generating sub-analyses suggest that certain at-risk groups may benefit. Atrial cardiopathy is associated with subclinical atrial fibrillation and research examining anticoagulation after ESUS in this population is underway. SUMMARY Stroke risk increases alongside burden of ectopic atrial activity. However, this risk may in part be because of prothrombotic dysfunction associated with atrial cardiopathy in addition to the arrhythmia itself. The minimal amount of subclinical atrial fibrillation to warrant anticoagulation for stroke prevention, and how this may be modified by the total duration of monitoring, will be clarified by the results of ongoing clinical trials. Currently research will also help identify whether a select group of ESUS patients who have structural and electrophysiological markers of atrial cardiopathy warrant anticoagulation for secondary prevention.
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23
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Kitsiou A, Rogalewski A, Kalyani M, Deelawar S, Tribunyan S, Greeve I, Minnerup J, Israel C, Schäbitz WR. Atrial Fibrillation in Patients with Embolic Stroke of Undetermined Source during 3 Years of Prolonged Monitoring with an Implantable Loop Recorder. Thromb Haemost 2021; 121:826-833. [PMID: 33401327 DOI: 10.1055/a-1346-2899] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Undocumented atrial fibrillation (AF) is suspected as a main stroke cause in patients with embolic stroke of undetermined source (ESUS), but its prevalence is largely unknown. This prospective study therefore aimed at delineating the prevalence of AF in patients with ESUS using continuous cardiac monitoring by implantable loop recorder (ILR) with daily remote interrogation over a period of 3 years and its clinical consequences, including recurrent stroke. METHODS In consecutive patients with an ESUS diagnosis after complete work-up, an ILR was implanted and followed by daily remote monitoring until AF was detected or a follow-up of at least 3 years was completed. Additionally, the ILR was interrogated in-hospital in 6-month intervals. RESULTS A total of 123 patients (74 male, mean age 65 ± 9 years) were enrolled and completed the 3 years study period. AF was detected in 51 patients (41.4%). In 43 of the 51 AF positive patients (84%) oral anticoagulation was established. Recurrent strokes occurred in 18 patients (14.6%) of this ESUS population, 9 of these patients being AF positive (17.6% of the AF-positive patients) and 9 being AF negative (12.5% of AF-negative patients). Patients with AF were slightly older than patients without AF (63.1 ± 8.8 vs. 67.5 ± 9.6 years, p = 0.12). Other parameters such as CHA2DS2-VASc score, infarct localization, micro- and macroangiopathy, carotid or aortic plaques, or stroke recurrence were not significantly different between groups. CONCLUSION In ESUS patients, early implantation of an ILR with cardiac monitoring and remote transmission over a 3-year period detected AF in 41.4% and resulted in oral anticoagulation in 84% of these patients.
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Affiliation(s)
- Alkisti Kitsiou
- Department of Neurology, Evangelical Hospital Bethel, Bielefeld, Germany
| | - Andreas Rogalewski
- Department of Neurology, Evangelical Hospital Bethel, Bielefeld, Germany
| | - Malik Kalyani
- Department of Cardiology, Evangelical Hospital Bethel, Bielefeld, Germany
| | - Sameera Deelawar
- Department of Cardiology, Evangelical Hospital Bethel, Bielefeld, Germany
| | - Sona Tribunyan
- Department of Cardiology, Evangelical Hospital Bethel, Bielefeld, Germany
| | - Isabell Greeve
- Department of Neurology, Evangelical Hospital Bethel, Bielefeld, Germany
| | - Jens Minnerup
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Carsten Israel
- Department of Cardiology, Evangelical Hospital Bethel, Bielefeld, Germany
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24
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Deering TF, Zannad F. Cardiac implantable electronic device-detected atrial fibrillation-"To anticoagulate or not to anticoagulate, that is the question": The noble or ignoble choice? Heart Rhythm 2020; 18:347-348. [PMID: 33181322 DOI: 10.1016/j.hrthm.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | - Faiez Zannad
- Université de Lorraine and Inserm and CHRU, Nancy, France
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25
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M Kochav S, A Reiffel J. The Link Between CHA 2DS 2-VASc Score and Thromboembolic Risk in Patients Without Known Atrial Fibrillation: Are We Missing a Silent Culprit? J Atr Fibrillation 2020; 12:2303. [PMID: 33024492 DOI: 10.4022/jafib.2303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 12/19/2019] [Accepted: 02/25/2020] [Indexed: 11/10/2022]
Abstract
Stroke is a leading cause of morbidity and mortality. The majority of strokes are ischemic and a subset of these are due to atrial fibrillation (AF). Other etiologies include a variety of cardiovascular disorders. The CHA2DS2-VASc score is a validated stroke prediction tool for patients with non-valvular AF. However, it has also been shown to predict increased risk for stroke or thromboembolism in the absence of AF. Given how common subclinical AF (SCAF) is when looked for in patients with elevated CHA2DS2-VaSc scores who are not known to have AF, (especially when implanted monitors are used), the stroke/thromboembolism risk that has been associated with CHA2DS2-VASc scores absent known AF may be an overestimate of the true risk due to the likely presence of SCAF in some of the subjects included. This has not yet been adequately addressed in the literature. Finally, the risk of a left atrial thromboembolic event is a consequence of the altered atrial anatomy and physiology (atrial cardiomyopathy) that may result from comorbid disorders and AF itself, or, additively from both - whether or not the AF has been already recognized clinically.
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Affiliation(s)
- Stephanie M Kochav
- Columbia University, Vagelos College of Physicians and Surgeons Division of Cardiology, Department of Medicine, New York, New York
| | - James A Reiffel
- Columbia University, Vagelos College of Physicians and Surgeons Division of Cardiology, Department of Medicine, New York, New York
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26
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Francisco-Pascual J, Olivella San Emeterio A, Rivas-Gándara N, Pérez-Rodón J, Benito B, Santos-Ortega A, Moya-Mitjans À, Rodríguez García J, Llerena Butrón SI, Cantalapiedra Romero J, Ferreira González I. High incidence of subclinical atrial fibrillation in patients with syncope monitored with implantable cardiac monitor. Int J Cardiol 2020; 316:110-116. [PMID: 32470530 DOI: 10.1016/j.ijcard.2020.05.078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 12/11/2022]
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27
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Riordan M, Opaskar A, Yoruk A, Younis A, Ali A, McNitt S, Sahin B, Rosero S, Goldenberg I, Aktas MK. Predictors of Atrial Fibrillation During Long-Term Implantable Cardiac Monitoring Following Cryptogenic Stroke. J Am Heart Assoc 2020; 9:e016040. [PMID: 32689866 PMCID: PMC7792281 DOI: 10.1161/jaha.120.016040] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Following cryptogenic stroke, guidelines recommend cardiac monitoring for occult atrial fibrillation (AF). We aimed to evaluate predictors of AF during long‐term implantable cardiac monitoring. Methods and Results We studied 293 consecutive patients who underwent implantable cardiac monitor implant (Medtronic LINQ) following hospitalization for cryptogenic stroke at the University of Rochester Medical Center from January 2013 to September 2018. Multivariable Cox proportional hazards regression modeling was used to identify predictors of AF during long‐term monitoring. At 36 months of follow‐up, the cumulative rate of implantable cardiac monitor–detected AF events was 32% in the total study population. Multivariable analysis identified age ≥70 years as the most powerful predictor of the development of AF events during follow‐up (hazard ratio, 2.28 [95% CI, 1.39–3.76]; P=0.001). Replacing age with the CHA2DS2‐VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, age, sex category) score resulted in a weaker association, for which each 1‐point increment in the CHA2DS2‐VASC score was associated with an 18% increased risk of developing AF (95% CI, 1.00–1.38; P=0.047). Consistent results were shown using Kaplan–Meier analysis by age and by the CHA2DS2VASc score. Conclusions Cryptogenic stroke patients continue to develop AF episodes during 36 months of implantable cardiac monitoring following the index event. Age is the most powerful predictor of occult AF in this population.
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Affiliation(s)
- Michael Riordan
- Department of Cardiology and Neurology Clinical Cardiovascular Research Center University of Rochester Medical Center Rochester New York
| | - Amanda Opaskar
- Department of Cardiology and Neurology Clinical Cardiovascular Research Center University of Rochester Medical Center Rochester New York
| | - Ayhan Yoruk
- Department of Cardiology and Neurology Clinical Cardiovascular Research Center University of Rochester Medical Center Rochester New York
| | - Arwa Younis
- Department of Cardiology and Neurology Clinical Cardiovascular Research Center University of Rochester Medical Center Rochester New York
| | - Adil Ali
- Department of Cardiology and Neurology Clinical Cardiovascular Research Center University of Rochester Medical Center Rochester New York
| | - Scott McNitt
- Department of Cardiology and Neurology Clinical Cardiovascular Research Center University of Rochester Medical Center Rochester New York
| | - Bogachan Sahin
- Department of Cardiology and Neurology Clinical Cardiovascular Research Center University of Rochester Medical Center Rochester New York
| | - Spencer Rosero
- Department of Cardiology and Neurology Clinical Cardiovascular Research Center University of Rochester Medical Center Rochester New York
| | - Ilan Goldenberg
- Department of Cardiology and Neurology Clinical Cardiovascular Research Center University of Rochester Medical Center Rochester New York
| | - Mehmet K Aktas
- Department of Cardiology and Neurology Clinical Cardiovascular Research Center University of Rochester Medical Center Rochester New York
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28
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Kochav SM, Reiffel JA. Detection of Previously Unrecognized (Subclinical) Atrial Fibrillation. Am J Cardiol 2020; 127:169-175. [PMID: 32423696 DOI: 10.1016/j.amjcard.2020.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 12/20/2022]
Abstract
Atrial fibrillation (AF) has been associated with increased morbidity and mortality, even when symptoms are absent and the arrhythmia is unrecognized (e.g., subclinical AF [SCAF]). Despite substantial evidence demonstrating an association between AF and adverse outcomes, the role of mass screening for previously unrecognized SCAF, such that its individual and population risks may be reduced by prophylactic therapy, remains uncertain. Many AF screening strategies exist, from pulse palpation and single-use devices to implanted cardiac monitors; however, existing guidelines are insufficient in specifying who to screen and for how long. In general, higher age, more (and more severe) comorbidities, and longer monitoring periods are associated with greater detection of SCAF. Herein we review the significance of previously unrecognized SCAF and current status of SCAF detection methods. We then propose a clinical approach to help clinicians incorporate AF screening into their practice. In conclusion, we report that SCAF may not be rare, that inserted cardiac monitors have the highest yield of SCAF detection, that clinical concern regarding SCAF is appropriate, but that evidence for therapy mandates is still being collected.
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29
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Diederichsen SZ, Haugan KJ, Kronborg C, Graff C, Højberg S, Køber L, Krieger D, Holst AG, Nielsen JB, Brandes A, Svendsen JH. Comprehensive Evaluation of Rhythm Monitoring Strategies in Screening for Atrial Fibrillation. Circulation 2020; 141:1510-1522. [DOI: 10.1161/circulationaha.119.044407] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background:
Stroke is an increasing health problem worldwide. Atrial fibrillation (AF) is a major risk factor for stroke, and the attention given to AF screening is rising, as new monitoring technologies emerge. We aimed to evaluate the performance of a large panel of screening strategies and to assess population characteristics associated with diagnostic yield.
Methods:
Individuals with stroke risk factors but without AF were recruited from the general population to undergo screening with an implantable loop recorder. New-onset AF lasting ≥6 minutes was adjudicated by senior cardiologists. After continuous monitoring for >3 years, complete day-to-day heart rhythm data sets were reconstructed for every participant, including exact time of onset and termination of all AF episodes. Random sampling was applied to assess the sensitivity and negative predictive value of screening with various simulated screening strategies compared with the implantable loop recorder. The diagnostic yield across strategies and population subgroups was compared by use of nonparametric tests.
Results:
The rhythm data sets comprised 590 participants enduring a total of 659 758 days of continuous monitoring and 20 110 AF episodes. In these data, a single 10-second ECG yielded a sensitivity (and negative predictive value) of 1.5% (66%) for AF detection, increasing to 8.3% (67%) for twice-daily 30-second ECGs during 14 days and to 11% (68%), 13% (68%), 15% (69%), 21% (70%), and 34% (74%) for a single 24-hour, 48-hour, 72-hour, 7-day, or 30-day continuous monitoring, respectively. AF detection further improved when subsequent screenings were performed or when the same monitoring duration was spread over several periods compared with a single period (eg, three 24-hour monitorings versus one 72-hour monitoring;
P
<0.0001 for all comparisons). The sensitivity was consistently higher among participants with age ≥75 years, male sex, CHADS
2
score >2, or NT-proBNP (N-terminal pro-B-type natriuretic peptide) ≥40 pmol/L and among participants with underlying ≥24-hour AF episodes compared with shorter AF (
P
<0.0001 for all screening strategies).
Conclusions:
In screening for AF among participants with stroke risk factors, the diagnostic yield increased with duration, dispersion, and number of screenings, although all strategies had low yield compared with the implantable loop recorder. The sensitivity was higher among participants who were older, were male, or had higher NT-proBNP.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier:
NCT02036450
.
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Affiliation(s)
| | - Ketil Jørgen Haugan
- Department of Cardiology, Zealand University Hospital Roskilde, Denmark (K.J.H.)
| | - Christian Kronborg
- Department of Business and Economics, University of Southern Denmark, Odense (C.K.)
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Denmark (C.G.)
| | - Søren Højberg
- Department of Cardiology, Bispebjerg Hospital (S.H.)
| | - Lars Køber
- Department of Cardiology, Rigshospitalet (S.Z.D., L.K., J.H.S.)
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (L.K., J.H.S.)
| | - Derk Krieger
- University Hospital Zurich, University of Zurich, Switzerland (D.K.)
- Stroke Unit, Mediclinic City Hospital, Dubai, United Arab Emirates (D.K.)
| | - Anders Gaarsdal Holst
- Laboratory for Molecular Cardiology, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.G.H., J.B.N., J.H.S.)
| | - Jonas Bille Nielsen
- Laboratory for Molecular Cardiology, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.G.H., J.B.N., J.H.S.)
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark (J.B.N.)
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Denmark (A.B.)
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense (A.B.)
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Rigshospitalet (S.Z.D., L.K., J.H.S.)
- Laboratory for Molecular Cardiology, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (A.G.H., J.B.N., J.H.S.)
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (L.K., J.H.S.)
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30
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Khan HA, Hanna N, Chaskes MJ, Gudleski GD, Karmilowicz P, Curtis AB. Screening for atrial fibrillation in high-risk nursing home residents. Heart Rhythm O2 2020; 1:10-13. [PMID: 34113854 PMCID: PMC8183881 DOI: 10.1016/j.hroo.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Various methods have been implemented for screening of patients for atrial fibrillation (AF), but the yield has generally been low. Targeting high-risk patients may improve detection of asymptomatic AF, which could be of value if appropriate treatment could be initiated before a potential thromboembolic event. Objective The purpose of this study was to test screening of high-risk nursing home residents having ≥2 risk factors for AF and no previous history of AF using a smartphone-based electrocardiographic (ECG) monitoring device to determine whether it is an accurate, easy-to-use method of screening for asymptomatic AF. Methods Study participants had ≥2 risk factors, consisting of age ≥75 years, female sex, obstructive sleep apnea, peripheral vascular disease, diabetes mellitus, obesity, hypertension, and congestive heart failure. Using the monitoring device, 30-second heart rhythm recordings were obtained on 4 different occasions. All tracings were reviewed by a cardiologist and, if uncertain, by an electrophysiologist. The nursing facility was notified of any diagnosis of AF, prompting further evaluation by the primary physician. Results Of the 245 residents screened, 18 (7.4%) had a diagnostic tracing for AF, 15 (83.3%) of whom had AF on the initial screen. There were no significant differences in demographics or individual risk factors between residents with and those without AF. Conclusion Intermittent ECG screening of high-risk nursing home residents using a simple, handheld device provided a diagnostic yield in our population comparable to that observed in past studies. Such screening of high-risk individuals can aid in the early diagnosis of AF and initiation of appropriate treatment.
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Giehm-Reese M, Kronborg MB, Lukac P, Kristiansen SB, Nielsen JM, Johannessen A, Jacobsen PK, Djurhuus MS, Riahi S, Hansen PS, Nielsen JC. Recurrent atrial flutter ablation and incidence of atrial fibrillation ablation after first-time ablation for typical atrial flutter: A nation-wide Danish cohort study. Int J Cardiol 2020; 298:44-51. [DOI: 10.1016/j.ijcard.2019.07.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/16/2019] [Accepted: 07/24/2019] [Indexed: 12/01/2022]
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32
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Passman R. Atrial fibrillation detection using implantable cardiac monitors: Are we being too revealing? Am Heart J 2020; 219:137-139. [PMID: 31862085 DOI: 10.1016/j.ahj.2019.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Rod Passman
- Northwestern University Feinberg School of Medicine and the Bluhm Cardiovascular Institute, Chicago, IL.
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33
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McIntyre W, Yong JHE, Sandhu R, Gladstone D, Simek K, Liu Y, Quinn F, Tytus R, Zizzo D, Henein S, Ivers N, Healey J. Prevalence of undiagnosed atrial fibrillation in elderly individuals and potential cost-effectiveness of non-invasive ambulatory electrocardiographic screening: The ASSERT-III study. J Electrocardiol 2020; 58:56-60. [DOI: 10.1016/j.jelectrocard.2019.11.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 11/01/2019] [Accepted: 11/08/2019] [Indexed: 12/11/2022]
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Reiffel JA, Verma A, Kowey PR, Halperin JL, Gersh BJ, Elkind MSV, Ziegler PD, Kaplon RE, Sherfesee L, Wachter R. Rhythm monitoring strategies in patients at high risk for atrial fibrillation and stroke: A comparative analysis from the REVEAL AF study. Am Heart J 2020; 219:128-136. [PMID: 31862084 DOI: 10.1016/j.ahj.2019.07.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/16/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reducing atrial fibrillation (AF)-related stroke requires timely AF diagnosis, but the optimal monitoring strategy is unknown. OBJECTIVE We used insertable cardiac monitor (ICM) data from the REVEAL AF study to compare AF detection rates by various short-term continuous monitoring (STM) strategies. METHODS AND RESULTS Patients without known AF, but with CHADS2 scores ≥3 (or = 2 with ≥1 additional AF risk factor) received an ICM for AF detection. One-time STM strategies were assessed by computing AF incidence at 1, 2, 7, 14, and 30 days post-ICM insertion. Repeated STM strategies (quarterly 24-hour, 48-hour, 7-day, or monthly 24-hour monitoring) were modeled by randomly selecting day(s) within a 30-day window around each nominal evaluation date over a 1-year period (simulated 10,000 times). Endpoints included AF ≥6 minutes, AF ≥1 hour, and daily AF burden ≥1 and ≥ 5.5 hours. The impact of compliance on AF detection was evaluated using daily compliance rates of 85%, 75%, 65% and 55% during follow-up months 1-3, 4-6, 7-9, and 9-12, respectively. Based on data from 385 patients (71.5 ± 9.9 years; CHADS2 score 3.0 ± 1.0) the incidence of AF ≥6 minutes via ICM at 12 months was 27.1% (95% CI, 22.5-31.5%). This exceeded the range of estimated rates from all modeled one-time and repeated STM strategies (0.8% for 24-hour Holter monitoring to 10.6% for quarterly 7-day monitoring). Findings were similar for all AF endpoints. Modeled non-compliance reduced AF detection by 4.5% to 22.9%. CONCLUSIONS Most AF episodes detected via ICMs would go undetected via conventional STM strategies, thus preventing optimal prophylaxis for adverse consequences.
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Affiliation(s)
- James A Reiffel
- Department of Medicine, Division of Cardiology, Vagelos College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY.
| | - Atul Verma
- Department of Cardiology, Southlake Regional Health Centre, 596 Davis Dr, Newmarket, ON, Canada.
| | - Peter R Kowey
- Department of Internal Medicine-Cardiology, Lankenau Institute for Medical Research, 100 Lancaster Ave, Wynnewood, PA.
| | - Jonathan L Halperin
- The Cardiovascular Institute, Mount Sinai Medical Center, 1190 5th Ave, New York, NY.
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN.
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, 710 West 168(th) Street, #182, New York, NY.
| | - Paul D Ziegler
- Diagnostics, Cardiac Rhythm and Heart Failure, Medtronic, Inc., 8200 Coral Sea St NE, Mounds View, MN.
| | - Rachelle E Kaplon
- Diagnostics, Cardiac Rhythm and Heart Failure, Medtronic, Inc., 8200 Coral Sea St NE, Mounds View, MN.
| | - Lou Sherfesee
- Diagnostics, Cardiac Rhythm and Heart Failure, Medtronic, Inc., 8200 Coral Sea St NE, Mounds View, MN.
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Liebigstraße 20, Leipzig, Germany.
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35
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Incidence and predictors of atrial fibrillation episodes as detected by implantable loop recorder in patients at risk: From the LOOP study. Am Heart J 2020; 219:117-127. [PMID: 31699295 DOI: 10.1016/j.ahj.2019.09.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/08/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent studies have suggested a high prevalence of subclinical atrial fibrillation (AF) in various patient populations, and interest in AF screening has increased. However, knowledge about episode duration is scarce, and risk factors for short or long subclinical AF episodes have yet to be recognized. The aim of the study was to assess AF by long-term continuous screening and to investigate predictors of episodes lasting ≥6 minutes, ≥5.5 hours, or ≥24 hours, respectively. METHODS A total of 597 patients aged ≥70 years and diagnosed with ≥1 of hypertension, diabetes, previous stroke, or heart failure were recruited from the general population to receive implantable loop recorder with remote monitoring. Exclusion criteria included history of AF or cardiac implantable electronic device. AF episodes were adjudicated by senior cardiologists. RESULTS During 40 (37; 42) months of continuous monitoring, AF was detected in 209 (35%) of the patients. The cumulative incidences at 3 years were 33.8% (30.2%-37.8%), 16.1% (13.4%-19.4%), and 5.7% (4.1%-7.9%) for AF episodes lasting ≥6 minutes, ≥5.5 hours, and ≥24 hours, respectively. Slower resting sinus rate and higher body mass index, N-terminal prohormone of brain natriuretic peptide, and troponin T at baseline were independently associated with AF detection. Addition of these markers to a model of sex, age, and comorbidities improved prediction of AF episodes ≥24 hours (time-dependent area under the receiver operating characteristic curve 79% vs 65%, P = .037). CONCLUSIONS A considerable burden of previously unknown AF was detected when long-term monitoring was applied in at-risk patients. Biomarkers were associated with AF incidence and improved prediction of long AF episodes.
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Abstract
Hypertension is the most common cardiovascular risk factor and underlies heart failure, coronary artery disease, stroke, and chronic kidney disease. Hypertensive heart disease can manifest as cardiac arrhythmias. Supraventricular and ventricular arrhythmias may occur in the hypertensive patients. Atrial fibrillation and hypertension contribute to an increased risk of stroke. Some antihypertensive drugs predispose to electrolyte abnormalities, which may result in atrial and ventricular arrhythmias. A multipronged strategy involving appropriate screening, aggressive lifestyle modifications, and optimal pharmacotherapy can result in improved blood pressure control and prevent the onset or delay progression of heart failure, coronary artery disease, and cardiac arrhythmias.
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Affiliation(s)
- Muhammad R Afzal
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Salvatore Savona
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Omar Mohamed
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Aayah Mohamed-Osman
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Steven J Kalbfleisch
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 473 West 12th Avenue, Suite 200, Columbus, OH 43210, USA.
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37
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Glotzer TV. The Naissance of Atrial Fibrillation. J Am Coll Cardiol 2019; 74:2782-2785. [PMID: 31779792 DOI: 10.1016/j.jacc.2019.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/03/2019] [Accepted: 10/06/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Taya V Glotzer
- Hackensack Meridian-Seton Hall School of Medicine, Rutgers New Jersey Medical School, Hackensack University Medical Center, Hackensack, New Jersey.
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38
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Burns RB, Zimetbaum P, Lubitz SA, Smetana GW. Should This Patient Be Screened for Atrial Fibrillation?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2019; 171:828-836. [PMID: 31791056 DOI: 10.7326/m19-1126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation (AFib) is the most common type of cardiac arrhythmia, affecting 2.7 million to 6.1 million persons in the United States. Although some persons with AFib have no symptoms, others do. For those without symptoms, AFib may be detected by 12-lead electrocardiogram (ECG), single-lead monitors (such as ambulatory blood pressure monitors and pulse oximeters), or consumer devices (such as wearable monitors and smartphones). Pulse palpation and heart auscultation also may detect AFib. In a systematic review, screening with ECG identified more new cases of AFib than no screening. Atrial fibrillation is an important cause of stroke, and without anticoagulant treatment, patients with AFib have approximately a 5-fold increased risk for stroke. The U.S. Preventive Services Task Force reviewed the benefits and harms of ECG screening for AFib in adults aged 65 years or older and found inadequate evidence that ECG identifies AFib more effectively than usual care. This conclusion is in contrast to guidelines from the European Society of Cardiology and the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand, which found that active screening for AFib in patients older than 65 years may be useful. Here, 2 cardiologists discuss the risks and benefits of screening for AFib, if and when they would recommend screening, and whether they would recommend anticoagulation for a patient with screen-detected AFib.
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Affiliation(s)
- Risa B Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., P.Z., G.W.S.)
| | - Peter Zimetbaum
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., P.Z., G.W.S.)
| | - Steven A Lubitz
- Massachusetts General Hospital, Boston Massachusetts (S.A.L.)
| | - Gerald W Smetana
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., P.Z., G.W.S.)
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39
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Natural History of Subclinical Atrial Fibrillation Detected by Implanted Loop Recorders. J Am Coll Cardiol 2019; 74:2771-2781. [DOI: 10.1016/j.jacc.2019.09.050] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/02/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
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40
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Schnabel RB, Haeusler KG, Healey JS, Freedman B, Boriani G, Brachmann J, Brandes A, Bustamante A, Casadei B, Crijns HJGM, Doehner W, Engström G, Fauchier L, Friberg L, Gladstone DJ, Glotzer TV, Goto S, Hankey GJ, Harbison JA, Hobbs FDR, Johnson LSB, Kamel H, Kirchhof P, Korompoki E, Krieger DW, Lip GYH, Løchen ML, Mairesse GH, Montaner J, Neubeck L, Ntaios G, Piccini JP, Potpara TS, Quinn TJ, Reiffel JA, Ribeiro ALP, Rienstra M, Rosenqvist M, Themistoclakis S, Sinner MF, Svendsen JH, Van Gelder IC, Wachter R, Wijeratne T, Yan B. Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration. Circulation 2019; 140:1834-1850. [PMID: 31765261 DOI: 10.1161/circulationaha.119.040267] [Citation(s) in RCA: 165] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.
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Affiliation(s)
- Renate B Schnabel
- University Heart Centre, Hamburg, Germany; German Cardiovascular Research Center (DZHK), Partner Site Hamburg/Kiel/Lübeck (R.B.-S.)
| | | | - Jeffrey S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
- Division of Cardiology, McMaster University; Arrhythmia Services, Hamilton Health Sciences; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J. Healey)
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Australia (B.F.)
| | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Italy (G.B.)
| | | | - Axel Brandes
- Odense University Hospital, Denmark (A. Brandes)
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebron (VHIR), Barcelona, Spain (A. Bustamante, J.M.)
| | - Barbara Casadei
- Division of Cardiovascular Medicine, British Heart Foundation Centre for Research Excellence, NIHR Oxford Biomedical Research Centre (B.C.), University of Oxford, United Kingdom
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center, the Netherlands (H.J.G.M.C.)
| | - Wolfram Doehner
- Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), partner site Berlin, and BIH Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Germany (W.D.)
| | - Gunnar Engström
- Department of Clinical Sciences, Lund University, Malmö, Sweden (G.E., L.J.)
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France (L.F.)
| | - Leif Friberg
- Karolinska Institute, Stockholm, Sweden (L.F., M. Rosenqvist)
| | - David J Gladstone
- Department of Medicine, University of Toronto; and Hurvitz Brain Sciences Program and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Canada (D.J.G.)
| | | | - Shinya Goto
- Tokai University School of Medicine, Metabolic Disease Research Center, Kanagawa, Japan (S.G.)
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth; and Department of Neurology, Sir Charles Gairdner Hospital, Perth, Australia (G.J.H.)
| | | | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Harris Manchester College (F.D.R.H.), University of Oxford, United Kingdom
| | - Linda S B Johnson
- Department of Clinical Sciences, Lund University, Malmö, Sweden (G.E., L.J.)
| | - Hooman Kamel
- Weill Cornell Medical College, New York, NY (H.K.)
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Sandwell and West Birmingham Hospitals and University Hospitals Birmingham NHS trusts, United Kingdom; AFNET, Muenster, Germany (P.K.)
| | - Eleni Korompoki
- Division of Brain Science, Imperial College London, United Kingdom (E.K.)
| | - Derk W Krieger
- Mohammed Bin Rashid University, Dubai, United Arab Emirates; and Neurosciences, Mediclinic City Hospital, Dubai, United Arab Emirates (D.W.K.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom (G.Y.H.L.)
| | - Maja-Lisa Løchen
- University Hospital of North Norway, Department of Cardiology, Tromsø (M.-L.L.)
| | | | - Joan Montaner
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebron (VHIR), Barcelona, Spain (A. Bustamante, J.M.)
| | - Lis Neubeck
- Edinburgh Napier University, United Kingdom (L.N.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.)
| | - Jonathan P Piccini
- Duke University Medical Center; and Duke Clinical Research Institute, Durham, NC (J.P.P.)
| | - Tatjana S Potpara
- Internal Medicine/Cardiology, School of Medicine, University of Belgrade, Serbia (T.S.P.)
| | - Terence J Quinn
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, United Kingdom (T.Q.)
| | - James A Reiffel
- Department of Medicine, Division of Cardiology, Columbia University, New York, NY (J.A.R.)
| | - Antonio Luiz Pinho Ribeiro
- Internal Medicine Department, School of Medicine, Federal University of Minas Gerais (UFMG); Hospital das Clínicas, UFMG, Belo Horizonte, Brazil (A.L.P.R.)
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M. Rienstra)
| | | | - Sakis Themistoclakis
- Unit of Electrophysiology and Cardiac Pacing, Ospedale dell'Angelo Venice-Mestre, Italy (T.S.)
| | - Moritz F Sinner
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilian's University, Munich, Germany (M.F.S.)
- German Centre for Cardiovascular Research, partner site: Munich Heart Alliance, Munich, Germany (M.F.S.)
| | - Jesper Hastrup Svendsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark (J.H.S.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (J.H.S.)
| | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, the Netherlands (I.v.G.)
| | - Rolf Wachter
- University Hospital Leipzig, Germany (R.W.)
- University Medicine Göttingen, Germany (R.W.)
- German Cardiovascular Research Center (DZHK), partner site: Göttingen (R.W.)
| | - Tissa Wijeratne
- Department of Neurology and Stroke Medicine, The University of Melbourne and Western Health, Australian Institute for Musculoskeletal Science (AIMSS), Sunshine Hospital St Albans, Australia (T.W.)
| | - Bernard Yan
- Royal Melbourne Hospital, Comprehensive Stroke Centre, Australia (B.Y.)
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41
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Kowey PR, Robinson VM. The Evolution of the One-Armed Bandit. J Am Coll Cardiol 2019; 74:2376-2378. [PMID: 31699277 DOI: 10.1016/j.jacc.2019.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Peter R Kowey
- Lankenau Institute for Medical Research, Main Line Health Heart Center, Wynnewood, Pennsylvania.
| | - Victoria M Robinson
- Lankenau Institute for Medical Research, Main Line Health Heart Center, Wynnewood, Pennsylvania; University of Manchester, Manchester, United Kingdom
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42
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Bertaglia E, Blank B, Blomström-Lundqvist C, Brandes A, Cabanelas N, Dan GA, Dichtl W, Goette A, de Groot JR, Lubinski A, Marijon E, Merkely B, Mont L, Piorkowski C, Sarkozy A, Sulke N, Vardas P, Velchev V, Wichterle D, Kirchhof P. Atrial high-rate episodes: prevalence, stroke risk, implications for management, and clinical gaps in evidence. Europace 2019; 21:1459-1467. [PMID: 31377792 PMCID: PMC6788209 DOI: 10.1093/europace/euz172] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/15/2019] [Indexed: 12/20/2022] Open
Abstract
Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10-30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.
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Affiliation(s)
- Emanuele Bertaglia
- Department of Cardiac, Vascular and Thoracic Sciences, Azienda Ospedaliera, Padua, Italy
| | | | | | - Axel Brandes
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Nuno Cabanelas
- Arrhythmias Unit of Cardiology Department, Hospital Prof. Dr. Fernando Fonseca, Amadora-Sintra, Portugal
| | - G -Andrei Dan
- Colentina University Hospital, Medicine University “Carol Davila”, Bucharest, Romania
| | - Wolfgang Dichtl
- University Hospital of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- St. Vincenz Hospital Paderborn, Cardiology and Intensive Care Medicine, Paderborn, Germany
| | - Joris R de Groot
- Department of Cardiology, Heart Center, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Andrzej Lubinski
- Department of Interventional Cardiology and Arrhythmias, Medical University of Lodz, Lodz, Poland
| | - Eloi Marijon
- Cardiac Electrophysiology Section, European Georges Pompidou Hospital, Paris, France
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University Budapest, Budapest, Hungary
| | - Lluis Mont
- Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain
| | | | | | - Neil Sulke
- Eastbourne District General Hospital, Eastbourne, UK
| | - Panos Vardas
- Heart Sector, Hygeia Group Hospitals, Athens, Greece
| | - Vasil Velchev
- Cardiology Clinic, St. Anna University Hospital, Medical University Sofia, Sofia, Bulgaria
| | - Dan Wichterle
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals NHS Trusts, IBR 126a, Wolfson Drive, Birmingham B15 2TT, UK
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43
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Tison GH, Sanchez JM, Ballinger B, Singh A, Olgin JE, Pletcher MJ, Vittinghoff E, Lee ES, Fan SM, Gladstone RA, Mikell C, Sohoni N, Hsieh J, Marcus GM. Passive Detection of Atrial Fibrillation Using a Commercially Available Smartwatch. JAMA Cardiol 2019; 3:409-416. [PMID: 29562087 DOI: 10.1001/jamacardio.2018.0136] [Citation(s) in RCA: 262] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Atrial fibrillation (AF) affects 34 million people worldwide and is a leading cause of stroke. A readily accessible means to continuously monitor for AF could prevent large numbers of strokes and death. Objective To develop and validate a deep neural network to detect AF using smartwatch data. Design, Setting, and Participants In this multinational cardiovascular remote cohort study coordinated at the University of California, San Francisco, smartwatches were used to obtain heart rate and step count data for algorithm development. A total of 9750 participants enrolled in the Health eHeart Study and 51 patients undergoing cardioversion at the University of California, San Francisco, were enrolled between February 2016 and March 2017. A deep neural network was trained using a method called heuristic pretraining in which the network approximated representations of the R-R interval (ie, time between heartbeats) without manual labeling of training data. Validation was performed against the reference standard 12-lead electrocardiography (ECG) in a separate cohort of patients undergoing cardioversion. A second exploratory validation was performed using smartwatch data from ambulatory individuals against the reference standard of self-reported history of persistent AF. Data were analyzed from March 2017 to September 2017. Main Outcomes and Measures The sensitivity, specificity, and receiver operating characteristic C statistic for the algorithm to detect AF were generated based on the reference standard of 12-lead ECG-diagnosed AF. Results Of the 9750 participants enrolled in the remote cohort, including 347 participants with AF, 6143 (63.0%) were male, and the mean (SD) age was 42 (12) years. There were more than 139 million heart rate measurements on which the deep neural network was trained. The deep neural network exhibited a C statistic of 0.97 (95% CI, 0.94-1.00; P < .001) to detect AF against the reference standard 12-lead ECG-diagnosed AF in the external validation cohort of 51 patients undergoing cardioversion; sensitivity was 98.0% and specificity was 90.2%. In an exploratory analysis relying on self-report of persistent AF in ambulatory participants, the C statistic was 0.72 (95% CI, 0.64-0.78); sensitivity was 67.7% and specificity was 67.6%. Conclusions and Relevance This proof-of-concept study found that smartwatch photoplethysmography coupled with a deep neural network can passively detect AF but with some loss of sensitivity and specificity against a criterion-standard ECG. Further studies will help identify the optimal role for smartwatch-guided rhythm assessment.
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Affiliation(s)
- Geoffrey H Tison
- Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - José M Sanchez
- Division of Cardiology, Department of Medicine, University of California, San Francisco
| | | | - Avesh Singh
- Cardiogram Incorporated, San Francisco, California
| | - Jeffrey E Olgin
- Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Emily S Lee
- Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - Shannon M Fan
- Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - Rachel A Gladstone
- Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - Carlos Mikell
- Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - Nimit Sohoni
- Cardiogram Incorporated, San Francisco, California
| | | | - Gregory M Marcus
- Division of Cardiology, Department of Medicine, University of California, San Francisco
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44
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Changes in Management Following Detection of Previously Unknown Atrial Fibrillation by an Insertable Cardiac Monitor (from the REVEAL AF Study). Am J Cardiol 2019; 124:864-870. [PMID: 31303247 DOI: 10.1016/j.amjcard.2019.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/04/2019] [Accepted: 06/06/2019] [Indexed: 12/23/2022]
Abstract
The REVEAL AF study demonstrated a high incidence of previously undetected atrial fibrillation (AF) using insertable cardiac monitors (ICMs) in patients with risk factors for AF and stroke. This analysis evaluated whether ICM monitoring led to changes in clinical management after AF detection. Patients with CHADS2 scores ≥3 (or =2 with ≥1 additional AF risk factor) but no history of AF received an ICM and were followed 18 to 30 months. Physicians recorded changes in clinical management in response to AF detection at scheduled (every 6 months) and unscheduled follow-up visits. Changes in clinical management included oral anticoagulation, rhythm or rate control pharmacotherapy, cardioversion, ablation, and cardiac subspecialist referral. In 387 patients who met inclusion criteria and received an ICM, AF was found in 115. A change in clinical management was taken in 87 patients with AF (76%). In 80 of these 87, a change was taken at the first visit after AF detection. In total, 31 patients (27%) with AF had ≥2 visits at which changes in clinical management were taken. The most common change was initiation of oral anticoagulation (n = 73, 63% of patients with AF). Patients with a change in clinical management at the first visit after AF detection tended to have longer AF episodes and a higher maximal daily AF burden compared with AF patients for whom no change was taken (longest episode: 52 vs 28 minutes; maximal daily AF burden:112 vs 23 minutes). Changes in management more frequently occurred at visits where patients reported AF-compatible symptoms (65% vs 46% of visits, p = 0.01). In conclusion, ICM monitoring to identify AF guides both immediate and long-term patient management in a population at high risk for stroke.
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45
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Rinciog CI, Sawyer LM, Diamantopoulos A, Elkind MSV, Reynolds M, Tsintzos SI, Ziegler PD, Quiroz ME, Wolff C, Witte KK. Cost-effectiveness of an insertable cardiac monitor in a high-risk population in the UK. Open Heart 2019; 6:e001037. [PMID: 31297227 PMCID: PMC6593196 DOI: 10.1136/openhrt-2019-001037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/16/2019] [Accepted: 04/26/2019] [Indexed: 01/08/2023] Open
Abstract
Objective To evaluate the cost-effectiveness of insertable cardiac monitors (ICMs) compared with standard of care (SoC) for detecting atrial fibrillation (AF) in patients at high risk of stroke (CHADS2 >2), using a UK National Health Service (NHS) perspective. Methods Using patient characteristics and clinical data from the REVEAL AF trial, a Markov model assessed the cost-effectiveness of detecting AF with an ICM compared with SoC. Costs and benefits were extrapolated across modelled patient lifetime. Ischaemic and haemorrhagic strokes, intracranial and extracranial haemorrhages and minor bleeds were modelled. Diagnostic and device costs were included, plus costs of treating stroke and bleeding events and costs of oral anticoagulants (OACs). Costs and health outcomes, measured as quality-adjusted life years (QALYs), were discounted at 3.5% per annum. One-way deterministic and probabilistic sensitivity analyses (PSA) were undertaken. Results The total per-patient cost for ICM was £13 360 versus £11 936 for SoC (namely, annual 24 hours Holter monitoring). ICMs generated a total of 6.50 QALYs versus 6.30 for SoC. The incremental cost-effectiveness ratio (ICER) was £7140/QALY gained, below the £20 000/QALY acceptability threshold. ICMs were cost-effective in 77.4% of PSA simulations. The number of ICMs needed to prevent one stroke was 21 and to cause a major bleed was 37. ICERs were sensitive to assumed proportions of patients initiating or discontinuing OAC after AF diagnosis, type of OAC used and how intense the traditional monitoring was assumed to be under SoC. Conclusions The use of ICMs to identify AF in a high-risk population is cost-effective for the UK NHS.
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Affiliation(s)
| | | | | | - Mitchell S V Elkind
- Neurology Department, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Matthew Reynolds
- Cardiovascular Medicine, Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Stylianos I Tsintzos
- Health Economics and Reimbursement, Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | - Paul D Ziegler
- Cardiac Rhythm and Heart Failure, Medtronic, Mounds View, Minnesota, USA
| | - Maria E Quiroz
- Cardiac Rhythm and Heart Failure, Medtronic, Mounds View, Minnesota, USA
| | - Claudia Wolff
- Health Economics and Reimbursement, Medtronic International Trading Sarl, Tolochenaz, Switzerland
| | - Klaus K Witte
- Division of Cardiovascular and Diabetes Research, University of Leeds, Leeds, UK
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46
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Reiffel JA, Verma A, Kowey PR, Halperin JL, Gersh BJ, Wachter R, Pouliot E, Ziegler PD. Incidence of Previously Undiagnosed Atrial Fibrillation Using Insertable Cardiac Monitors in a High-Risk Population: The REVEAL AF Study. JAMA Cardiol 2019; 2:1120-1127. [PMID: 28842973 DOI: 10.1001/jamacardio.2017.3180] [Citation(s) in RCA: 187] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance In approximately 20% of atrial fibrillation (AF)-related ischemic strokes, stroke is the first clinical manifestation of AF. Strategies are needed to identify and therapeutically address previously undetected AF. Objective To quantify the incidence of AF in patients at high risk for but without previously known AF using an insertable cardiac monitor. Design, Setting, and Participants This prospective, single-arm, multicenter study was conducted from November 2012 to January 2017. Visits took place at 57 centers in the United States and Europe. Patients with a CHADS2 score of 3 or greater (or 2 with at least 1 additional risk factor) were enrolled. Approximately 90% had nonspecific symptoms potentially compatible with AF, such as fatigue, dyspnea, and/or palpitations. Exposures Patients underwent monitoring with an insertable cardiac monitor for 18 to 30 months. Main Outcomes and Measures The primary end point was adjudicated AF lasting 6 or more minutes and was assessed at 18 months. Other analyses included detection rates at points from 30 days to 30 months and among CHADS2 score subgroups. Median time from insertion to detection and the percentage of patients subsequently prescribed oral anticoagulation therapy was also determined. Results A total of 446 patients were enrolled; 233 (52.2%) were male, and the mean (SD) age was 71.5 (9.9) years. A total of 385 patients (86.3%) received an insertable cardiac monitor, met the primary analysis cohort definition, and were observed for a mean (SD) period of 22.5 (7.7) months. The detection rate of AF lasting 6 or more minutes at 18 months was 29.3%. Detection rates at 30 days and 6, 12, 24, and 30 months were 6.2%, 20.4%, 27.1%, 33.6%, and 40.0%, respectively. At 18 months, AF incidence was similar among patients with CHADS2 scores of 2 (24.7%; 95% CI, 17.3-31.4), 3 (32.7%; 95% CI, 23.8-40.7), and 4 or greater (31.7%; 95% CI, 22.0-40.3) (P = .23). Median (interquartile) time from device insertion to first AF episode detection was 123 (41-330) days. Of patients meeting the primary end point, 13 (10.2%) had 1 or more episodes lasting 24 hours or longer, and oral anticoagulation therapy was prescribed for 72 patients (56.3%). Conclusions and Relevance The incidence of previously undiagnosed AF may be substantial in patients with risk factors for AF and stroke. Atrial fibrillation would have gone undetected in most patients had monitoring been limited to 30 days. Further trials regarding the value of detecting subclinical AF and of prophylactic therapies are warranted. Trial Registration clinicaltrials.gov Identifier: NCT01727297.
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Affiliation(s)
- James A Reiffel
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Peter R Kowey
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | | | | | - Rolf Wachter
- Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
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Reiffel JA. Pills Never Work in the Bottle. J Am Coll Cardiol 2019; 70:1584-1586. [PMID: 28935035 DOI: 10.1016/j.jacc.2017.07.771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 07/17/2017] [Accepted: 07/18/2017] [Indexed: 10/18/2022]
Affiliation(s)
- James A Reiffel
- Department of Medicine, Division of Cardiology, Columbia University, New York, New York.
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Gahungu N, Judkins C, Gabbay E, Playford D. Advances in screening for undiagnosed atrial fibrillation for stroke prevention and implications for patients with obstructive sleep apnoea: a literature review and research agenda. Sleep Med 2019; 57:107-114. [DOI: 10.1016/j.sleep.2019.01.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/30/2018] [Accepted: 01/30/2019] [Indexed: 02/03/2023]
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Sakhi R, Theuns DAMJ, Szili-Torok T, Yap SC. Insertable cardiac monitors: current indications and devices. Expert Rev Med Devices 2018; 16:45-55. [PMID: 30522350 DOI: 10.1080/17434440.2018.1557046] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Recurrent unexplained syncope is a well-established indication for an insertable cardiac monitor (ICM). Recently, the indications for an ICM have been expanded. AREAS COVERED This review article discusses the current indications for ICMs and gives an overview of the latest generation of commercially available ICMs. EXPERT COMMENTARY The 2018 ESC Syncope guidelines have expanded the indications for an ICM to patients with inherited cardiomyopathy, inherited channelopathy, suspected unproven epilepsy, and unexplained falls. ICMs are also increasingly used for the detection of subclinical atrial fibrillation (AF) in patients with cryptogenic stroke. Whether treatment of subclinical AF (SCAF) with oral anticoagulation prevents recurrent stroke is yet unknown. The current generation of ICMs are smaller, easier to implant, have better diagnostics, and are capable of remote monitoring. The Reveal LINQ (Medtronic) is the smallest ICM and has the most extensive performance and clinical data. The BioMonitor 2 (Biotronik) is the largest ICM but has excellent R-wave amplitudes, longest longevity, and reliable remote monitoring. The Confirm Rx (Abbott) is capable to provide mobile data transmission enabled by a smartphone app. Future generation of ICMs will incorporate heart failures indices to facilitate remote monitoring of heart failure patients.
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Affiliation(s)
- Rafi Sakhi
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Dominic A M J Theuns
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Tamas Szili-Torok
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Sing-Chien Yap
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
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Yeung C, Drew D, Hammond S, Hopman WM, Redfearn D, Simpson C, Abdollah H, Baranchuk A. Extended Cardiac Monitoring in Patients With Severe Sleep Apnea and No History of Atrial Fibrillation (The Reveal XT-SA Study). Am J Cardiol 2018; 122:1885-1889. [PMID: 30274768 DOI: 10.1016/j.amjcard.2018.08.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/07/2018] [Accepted: 08/13/2018] [Indexed: 11/18/2022]
Abstract
Atrial fibrillation (AF) is a risk factor for ischemic stroke and reported to be associated with severe obstructive sleep apnea (OSA). The aim of this study was to determine the occurrence of newly detected AF in patients with severe OSA and no previous history of AF. Prospective observational study included patients with severe OSA (Apnea-Hypopnea Index [AHI] ≥ 30) and no history of AF. Primary outcome was detection of AF lasting ≥10 seconds. Patients were subjected to 2 24-hour Holter monitors, and if no AF was detected, implanted with a Medtronic Reveal XT implantable loop recorder. Follow-up was done every 6 months for a total of 3years. Implantable loop recorder was explanted if the primary outcome was detected (AF) or the battery was exhausted. Of the 31 patients enrolled, 6 withdrew participation in the study before implantation. Mean age was 57 ± 10years, mean body mass index was 35 ± 6; 52% male patients. Hypertension 56% and coronary artery disease 24%. Mean AHI was 55 ± 18. AF was detected in 5 patients (20%). AF mean duration was 4.8hours (range 20 seconds to 15.3 hours). Mean time to diagnosis was 11 ± 7 months. Male gender was predictive for AF detection (p = 0.04). Continuous positive airway pressure therapy was used by 96% of patients with 68% total adherence. Mean follow-up was 27 months. In conclusion, extended cardiac monitoring of patients with severe OSA may facilitate the identification of newly detected AF.
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Affiliation(s)
- Cynthia Yeung
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Doran Drew
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Sharlene Hammond
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Wilma M Hopman
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Damian Redfearn
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Christopher Simpson
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Hoshiar Abdollah
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Kingston Health Sciences Centre, Queen's University, Kingston, Ontario, Canada.
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