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Pezawas T. ECG Smart Monitoring versus Implantable Loop Recorders for Atrial Fibrillation Detection after Cryptogenic Stroke-An Overview for Decision Making. J Cardiovasc Dev Dis 2023; 10:306. [PMID: 37504563 PMCID: PMC10380665 DOI: 10.3390/jcdd10070306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/29/2023] [Accepted: 06/12/2023] [Indexed: 07/29/2023] Open
Abstract
Up to 20% of patients with ischemic stroke or transient ischemic attack have a prior history of known atrial fibrillation (AF). Additionally, unknown AF can be detected by different monitoring strategies in up to 23% of patients with cryptogenic or non-cardioembolic stroke. However, most studies had substantial gaps in monitoring time, especially early after the index event. Following this, AF rates would be higher if patients underwent continuous monitoring early after stroke, avoiding any gaps in monitoring. The few existing randomized studies focused on patients with cryptogenic stroke but did not focus otherwise specifically on prevention strategies in patients at high risk for AF (patients at higher age or with high CHA2DS2-VASC scores). Besides invasive implantable loop recorders (ILRs), external loop recorders (ELRs) and mobile cardiac outpatient telemetry (MCOT) are non-invasive tools that are commonly used for long-term ECG monitoring in cryptogenic-stroke patients in the ambulatory setting. The role of MCOT and hand-held devices within ECG smart monitoring in the detection of AF for the prevention of and after cryptogenic stroke is currently unclear. This intense review provides an overview of current evidence, techniques, and gaps in knowledge and aims to advise which patients benefit most from the current available devices.
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Affiliation(s)
- Thomas Pezawas
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Al Qurashi AA, Rasheed F, Siddiqi AR, Abdullah M, Mumtaz M, Khan T, Mallick AH, Jabeen S, Ahmed IE, Ochani RK. Insertable cardiac monitoring devices versus external cardiac monitoring for detecting atrial fibrillation and preventing the recurrence of stroke: A systematic review and meta-analysis. J Electrocardiol 2023; 77:29-36. [PMID: 36577318 DOI: 10.1016/j.jelectrocard.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 10/25/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Atrial Fibrillation (AF) is a major risk factor for stroke, which is the second leading cause of death worldwide. It remains uncertain whether insertable cardiac monitors (ICMs) enhance the ability to recognize AF over external cardiac monitoring in patients who have experienced a stroke. AIM We conducted a systematic review and meta-analysis to determine whether ICM devices are more effective than external cardiac monitoring for the detection of AF in stroke patients. METHODS We included studies that reported an AF detection rate in stroke patients with a follow-up of at least 12 months. We analyzed the data of 1233 patients from 3 randomized control trials (RCTs). RESULTS When compared to external cardiac monitoring, ICM devices (Medtronic Reveal LINQ and Reveal XT) showed a significantly higher detection rate of AF (RR = 5.04, 95% CI = 2.93-8.68; p < 0.05; ARR = 10.47%, NNT = 10). The ICM arm had significantly higher usage of oral anticoagulants (OAC) as compared to the control arm. (RR = 2.76, 95% CI = 1.89-4.02, p < 0.05). Additionally, ICM usage was associated with a higher incidence of mild to moderate adverse events (RR = 10.52, 95% CI =1.35-82.14; p = 0.02) and a higher number of severe adverse events as compared to the control arm (RR = 7.61, 95% CI = 1.36-42.51; p = 0.02). CONCLUSION ICM devices are associated with better detection rates of AF and higher usage of OAC as compared to external cardiac monitoring in post-stroke patients. However, ICM insertion is associated with a higher incidence of mild/moderate and severe adverse effects.
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Affiliation(s)
- Abdullah A Al Qurashi
- College of Medicine, King Saud bin Abdul Aziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Faisal Rasheed
- Allama Iqbal Medical College, Affiliated with University of Health Sciences, Lahore, Pakistan.
| | - Ahsun Rizwan Siddiqi
- Wah Medical College, Affiliated with University of Health Sciences, Wah, Pakistan
| | | | - Mishal Mumtaz
- Quaid-e-Azam Medical College, Affiliated with University of Health Sciences, Lahore, Pakistan
| | - Tehrim Khan
- Wah Medical College, Affiliated with University of Health Sciences, Wah, Pakistan
| | - Abbas Hayat Mallick
- Fatima Memorial College of Medicine & Dentistry/Department of Medicine, Fatima Memorial Hospital, Lahore, Pakistan
| | - Sidra Jabeen
- Liaquat National Hospital and Medical College, Affiliated with Jinnah Sindh Medical University, Karachi, Pakistan
| | - Ifra Eeman Ahmed
- Federal Medical and Dental College, Affiliated with Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan
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Barthelemy JC, Pichot V, Hupin D, Berger M, Celle S, Mouhli L, Bäck M, Lacour JR, Roche F. Targeting autonomic nervous system as a biomarker of well-ageing in the prevention of stroke. Front Aging Neurosci 2022; 14:969352. [PMID: 36185479 PMCID: PMC9521604 DOI: 10.3389/fnagi.2022.969352] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Stroke prediction is a key health issue for preventive medicine. Atrial fibrillation (AF) detection is well established and the importance of obstructive sleep apneas (OSA) has emerged in recent years. Although autonomic nervous system (ANS) appears strongly implicated in stroke occurrence, this factor is more rarely considered. However, the consequences of decreased parasympathetic activity explored in large cohort studies through measurement of ANS activity indicate that an ability to improve its activity level and equilibrium may prevent stroke. In support of these observations, a compensatory neurostimulation has already proved beneficial on endothelium function. The available data on stroke predictions from ANS is based on many long-term stroke cohorts. These data underline the need of repeated ANS evaluation for the general population, in a medical environment, and remotely by emerging telemedicine digital tools. This would help uncovering the reasons behind the ANS imbalance that would need to be medically adjusted to decrease the risk of stroke. This ANS unbalance help to draw attention on clinical or non-clinical evidence, disclosing the vascular risk, as ANS activity integrates the cumulated risk from many factors of which most are modifiable, such as metabolic inadaptation in diabetes and obesity, sleep ventilatory disorders, hypertension, inflammation, and lack of physical activity. Treating these factors may determine ANS recovery through the appropriate management of these conditions. Natural aging also decreases ANS activity. ANS recovery will decrease global circulating inflammation, which will reinforce endothelial function and thus protect the vessels and the associated organs. ANS is the whistle-blower of vascular risk and the actor of vascular health. Such as, ANS should be regularly checked to help draw attention on vascular risk and help follow the improvements in response to our interventions. While today prediction of stroke relies on classical cardiovascular risk factors, adding autonomic biomarkers as HRV parameters may significantly increase the prediction of stroke.
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Affiliation(s)
- Jean-Claude Barthelemy
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
- *Correspondence: Jean-Claude Barthelemy,
| | - Vincent Pichot
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
| | - David Hupin
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
- Section of Translational Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Mathieu Berger
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
- Centre d’Investigation et de Recherche sur le Sommeil, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Sébastien Celle
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
| | - Lytissia Mouhli
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- Département de Neurologie, Hôpital Universitaire Nord, Saint-Étienne, France
| | - Magnus Bäck
- Section of Translational Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jean-René Lacour
- Laboratoire de Physiologie, Faculté de Médecine Lyon-Sud, Oullins, France
| | - Frederic Roche
- Physical Exercise and Clinical Physiology Department, CHU Nord, Saint-Étienne, France
- INSERM U1059 Santé Ingénierie Biologie, Université Jean Monnet, Saint-Étienne, France
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Bhat A, Mahajan V, Chen HHL, Gan GCH, Pontes-Neto OM, Tan TC. Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism. Stroke 2021; 52:e820-e836. [PMID: 34706562 DOI: 10.1161/strokeaha.121.034498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Vipul Mahajan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Medicine (G.C.H.G.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavior, Ribeirão Preto Medical School, University of São Paulo, Brazil (O.M.P.-N.)
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
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Abstract
Background Many stroke survivors suffer recurrent stroke because paroxysmal atrial fibrillation (AF) was missed and no preventive anticoagulation initiated. This prospective cohort study determined the added diagnostic yield of second-look 24-h electrocardiographic recording (ECG) in a population at high risk for AF: patients who suffered a stroke of such severity that they require inpatient neurorehabilitation. Methods We enrolled 508 patients with ischemic stroke admitted to post-acute inpatient neurorehabilitation and determined whether AF was detected during acute care at the referring hospital. Second-look baseline and 24-h Holter ECG were then conducted during neurorehabilitation. Primary outcome was number of newly detected AF with duration of > 30 s; secondary outcomes were number of newly detected absolute arrhythmia of 10–30 s and < 10 s duration. For comparison, we further enrolled 100 patients with hemorrhagic stroke without history of AF (age = 72 + 11 years, 51% female). Results In 206 of the 508 ischemic stroke patients, AF had been detected during acute phase work-up (age = 78 + 10 years, 55% female). For the remaining 302 ischemic stroke patients, no AF was detected during acute phase work-up (age = 74 + 9 years; 47% female). Second-look 24-h ECG showed previously missed AF of > 30 s in 20 of these patients, i.e. 6.6% of the sample, and shorter absolute arrhythmia in 50 patients (i.e. 16.5%). Conclusions Second-look 24-Hour ECG performed during post-acute inpatient neurorehabilitation has a high diagnostic yield and should become a standard component of recurrent stroke prevention.
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Vollmuth C, Stoesser S, Neugebauer H, Hansel A, Dreyhaupt J, Ludolph AC, Kassubek J, Althaus K. MR-imaging pattern is not a predictor of occult atrial fibrillation in patients with cryptogenic stroke. J Neurol 2019; 266:3058-3064. [PMID: 31511980 PMCID: PMC6851041 DOI: 10.1007/s00415-019-09524-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/27/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
Background To date, insertable cardiac monitors (ICMs) are the most effective method for the detection of occult atrial fibrillation (AF) in cryptogenic stroke. The overall detection rate after 12 months, however, is low and ranges between 12.4 and 33.3%, even if clinical predictors are considered. Ischemic stroke patients due to cardiogenic embolism present with particular lesion patterns. In patients with cryptogenic stroke, MR-imaging pattern may be a valuable predictor for AF. Methods This is an MRI-based, retrospective, observational, comparative, single-center study of 104 patients who underwent ICM implantation after cryptogenic stroke. The findings were compared to a reference group with related stroke etiology, i.e., 166 patients with embolic stroke due to AF detected for the first time by long-term ECG. Lesion patterns were evaluated with regard to affected territories, distribution (cortical, lacunar, scattered), lesion volume, and lesion size (diameter of the lesion size > 20 mm). Results The MR-imaging analysis of acute ischemic lesions yielded no association between AF and lesion size or volume, arterial vessel distribution, or the number of affected territories. There was no significant difference between the cohorts regarding ischemic patterns (cortical lesions, scattered lesions, and lacunar infarcts). An important clinical inference of our findings is that 10% (2 of 20) of cases in the ICM group in whom AF was detected had a lacunar infarct pattern. Similar results were shown in cases of ischemic stroke patients with AF detected for the first time by long-term ECG, with 10.9% (16 of 147) of them showing lacunar infarcts. The analysis of chronic MRI lesions revealed no differences between the groups in the rate of chronic lesions, arterial vessel distribution, or the number of affected territories. Left atrial size (LA size) and the presence of atrial runs in long-term ECG were independently associated with AF. Conclusions In this MRI-based analysis of patients with cryptogenic stroke who had received ICM implantation, the detection rate of AF in patients with ICM was not related to the imaging pattern. In addition, the lacunar infarct pattern should not be an exclusion criterion for ICM insertion in patients with cryptogenic stroke. ICM insertion in patients with cryptogenic stroke should not be evaluated solely on the basis of reference to infarct patterns.
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Affiliation(s)
- C Vollmuth
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - S Stoesser
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department of Neurology, University of Bonn, Bonn, Germany
| | - H Neugebauer
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - A Hansel
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
- Department for Psychiatry and Psychotherapy, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - J Dreyhaupt
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - A C Ludolph
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - J Kassubek
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - K Althaus
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, 89081, Ulm, Germany.
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Ikama SM, Makani J, Mpandzou G, Ossou-Nguiet PM, Nsitou BM, Lambi MN, Matali E, Gombet TR, Kaky SGK. [Contribution of Holter ECG in the etiologic diagnosis of the ischemic stroke in Brazzaville, Congo]. Pan Afr Med J 2019; 31:235. [PMID: 31447992 PMCID: PMC6691285 DOI: 10.11604/pamj.2018.31.235.17709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 12/02/2018] [Indexed: 12/27/2022] Open
Abstract
Déterminer la prévalence des troubles rythmiques au cours des infarctus cérébraux et identifier les facteurs prédictifs de la fibrillation atriale (FA) paroxystique. Il s'est agi d'une étude transversale, descriptive et analytique, menée à Brazzaville entre janvier 2012 et décembre 2016. Elle a porté sur une série consécutive de 267 patients victimes d'un accident vasculaire cérébral ischémique transitoire (n = 17) ou constitué (n = 250), documenté par un scanner cérébral. Tous ces patients ont bénéficié d'un enregistrement Holter ECG dès 24h, réalisé dans le cadre de la recherche étiologique. Les principales anomalies rythmiques enregistrées ont été répertoriées et la régression logistique a permis l'identification des facteurs prédictifs de survenue de la FA paroxystique. Il s'agissait de 164 hommes (61,4%) et 103 femmes (38,6%), âgés en moyenne de 60,2 ± 12,1 ans (extrêmes: 22 et 94 ans). Les principaux facteurs de risque cardiovasculaire identifiés étaient une hypertension artérielle (HTA) dans 214 cas (80,1%), un diabète sucré dans 36 cas (13,5%), et un tabagisme dans 18 cas (6,7%), avec un taux de cumul de 1,5 facteur par individu. L'examen Holter ECG, normal dans 216 cas (81%), était pathologique dans 51 cas (19%). Les principales anomalies enregistrées consistaient en des extrasystoles ventriculaires bénignes (n = 32), une FA paroxystique (n = 7), des extrasystoles supraventriculaires (n = 5), une tachycardie ventriculaire (TV) non soutenue (n = 4), une TV soutenue (n = 2) et un bloc auriculo-ventriculaire type Mobitz II (n = 1). La fréquence de la FA paroxystique était de 2,6%. En analyse bivariée, il n'a pas été noté de corrélation entre la FA paroxystique et le sexe (p = 0,890), l'HTA (p = 0,818), le diabète (p = 0,839), le tabac (p = 0,969). En analyse multivariée, seul l'âge était prédictif de la survenue d'une FA paroxystique au cours des infarctus cérébraux (OR = 1,11;p = 0,0134). Il ressort de cette étude préliminaire que les troubles du rythme emboligènes sont relativement rares au cours des infarctus cérébraux à Brazzaville. La FA paroxystique, quoique peu fréquente, reste essentiellement corrélée à l'âge. Sa recherche systématique chez les sujets âgés contribue à améliorer la prise en charge.
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Affiliation(s)
- Stéphane Méo Ikama
- Service de Cardiologie, Centre Hospitalier Universitaire de Brazzaville, Congo
| | - Jospin Makani
- Service de Cardiologie, Centre Hospitalier Universitaire de Brazzaville, Congo
| | - Ghislain Mpandzou
- Service de Neurologie, Centre Hospitalier Universitaire de Brazzaville, Congo
| | | | | | - Munka Nkalla Lambi
- Service de Cardiologie, Centre Hospitalier Universitaire de Brazzaville, Congo
| | - Edgard Matali
- Service de Neurologie, Centre Hospitalier Universitaire de Brazzaville, Congo
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Renati S, Stone DK, Almeida L, Wilson CA. Predictors of Atrial Fibrillation in Patients With Cryptogenic Stroke. Neurohospitalist 2019; 9:127-132. [PMID: 31244968 DOI: 10.1177/1941874418819619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background and Purpose Many patients diagnosed with cryptogenic stroke or transient ischemic attack are subsequently found to have atrial fibrillation (AF) on outpatient cardiac telemetry monitoring. Identification of predictive factors for the detection of AF could assist with patient selection to increase the yield of telemetry and hasten initiation of appropriate secondary stroke prevention. Methods This was a retrospective cross-sectional study of patients diagnosed with cryptogenic stroke at a comprehensive stroke center and referred for at least 21 days of prolonged outpatient telemetry. Telemetry reports and data from the patient's stroke hospitalization, including imaging studies, electrocardiogram (EKG), echocardiogram, vital signs, and laboratory data, were reviewed. Results Ten percent of the 121 patients included in the study were diagnosed with AF based on outpatient telemetry. There was a strong association between presence of premature atrial contractions (PACs) on admission EKG and subsequent detection of AF (P = .004). Large left atrial diameter on echocardiogram was correlated with AF detection in males (P = .024). However, there was no association between AF and other echocardiographic measurements. Thyroid-stimulating hormone (TSH) levels were significantly higher in patients with cryptogenic stroke having AF (P = .008), with a TSH greater than 4.20 mIU/L predictive of detection of AF (P < .001). Conclusions Atrial fibrillation was found by outpatient monitoring in a notable percentage of patients with cryptogenic stroke. Predictors of occult AF in our study population included PACs and higher TSH levels. Although an association between low TSH and AF has been well established, our results suggest that high TSH may be a predictive factor as well.
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Affiliation(s)
- Swetha Renati
- Department of Neurology, University of South Florida, Tampa, FL, USA
| | - David K Stone
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Leonardo Almeida
- Department of Neurology, University of Florida, Gainesville, FL, USA
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Ramkumar S, Nerlekar N, D'Souza D, Pol DJ, Kalman JM, Marwick TH. Atrial fibrillation detection using single lead portable electrocardiographic monitoring: a systematic review and meta-analysis. BMJ Open 2018; 8:e024178. [PMID: 30224404 PMCID: PMC6144487 DOI: 10.1136/bmjopen-2018-024178] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/13/2018] [Accepted: 08/17/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Recent technology advances have allowed for heart rhythm monitoring using single-lead ECG monitoring devices, which can be used for early diagnosis of atrial fibrillation (AF). We sought to investigate the AF detection rate using portable ECG devices compared with Holter monitoring. SETTING, PARTICIPANTS AND OUTCOME MEASURES We searched the Medline, Embase and Scopus databases (conducted on 8 May 2017) using search terms related to AF screening and included studies with adults aged >18 years using portable ECG devices or Holter monitoring for AF detection. We excluded studies using implantable loop recorders and pacemakers. Using a random-effects model we calculated the overall AF detection rate. Meta-regression analysis was performed to explore potential sources for heterogeneity. Quality of reporting was assessed using the tool developed by Downs and Black. RESULTS Portable ECG monitoring was used in 18 studies (n=117 436) and Holter monitoring was used in 36 studies (n=8498). The AF detection rate using portable ECG monitoring was 1.7% (95% CI 1.4 to 2.1), with significant heterogeneity between studies (p<0.001). There was a moderate linear relationship between total monitoring time and AF detection rate (r=0.65, p=0.003), and meta-regression identified total monitoring time (p=0.005) and body mass index (p=0.01) as potential contributors to heterogeneity. The detection rate (4.8%, 95% CI 3.6% to 6.0%) in eight studies (n=10 199), which performed multiple ECG recordings was comparable to that with 24 hours Holter (4.6%, 95% CI 3.5% to 5.7%). Intermittent recordings for 19 min total produced similar AF detection to 24 hours Holter monitoring. CONCLUSION Portable ECG devices may offer an efficient screening option for AF compared with 24 hours Holter monitoring. PROSPERO REGISTRATION NUMBER CRD42017061021.
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Affiliation(s)
- Satish Ramkumar
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria, Australia
- Monash Heart, Monash Cardiovascular Research Centre, Melbourne, Victoria, Australia
| | - Nitesh Nerlekar
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Monash Heart, Monash Cardiovascular Research Centre, Melbourne, Victoria, Australia
| | - Daniel D'Souza
- Monash Heart, Monash Cardiovascular Research Centre, Melbourne, Victoria, Australia
| | - Derek J Pol
- Monash Heart, Monash Cardiovascular Research Centre, Melbourne, Victoria, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital and the Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria, Australia
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10
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Higuchi S, Kabeya Y, Matsushita K, Tachibana K, Kawachi R, Takei H, Suzuki Y, Abe N, Imanishi Y, Moriyama K, Yorozu T, Saito K, Sugiyama M, Kondo H, Yoshino H. The study protocol for PREDICT AF RECURRENCE: a PRospEctive cohort stuDy of surveIllanCe for perioperaTive Atrial Fibrillation RECURRENCE in major non-cardiac surgery for malignancy. BMC Cardiovasc Disord 2018; 18:127. [PMID: 29940875 PMCID: PMC6019832 DOI: 10.1186/s12872-018-0862-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 06/11/2018] [Indexed: 12/24/2022] Open
Abstract
Background A previous retrospective cohort study established the relationship between perioperative atrial fibrillation (POAF) and subsequent mortality and stroke. However, the details regarding the cause of death and etiology of stroke remain unclear. Methods The prospective cohort study of surveillance for perioperative atrial fibrillation recurrence in major non-cardiac surgery for malignancy (PREDICT AF RECURRENCE) registry is an ongoing prospective cohort study to elucidate the long-term recurrence rate and the clinical impact of new-onset POAF in the setting of head and neck, non-cardiac thoracic, and abdominal surgery for malignancy. In this study, cardiologists collaborate with a surgical team during the perioperative period, carefully observe the electrocardiogram (ECG) monitor, and treat arrhythmia as required. Furthermore, patients who develop new-onset POAF are followed up using a long-term Holter ECG monitor, SPIDER FLASH-t AFib®, to assess POAF recurrence. Discussion Even if patients with malignancy survive by overcoming the disease, they may die from any preventable cardiovascular diseases. In particular, those with POAF may develop cardiogenic stroke in the future. Because details of the natural history of patients with POAF remain unclear, investigating the need to continue anticoagulation therapy for such patients is necessary. This study will provide essential information on the recurrence rate of POAF and new insights into the prediction and treatment of POAF. Trial registration University Hospital Medical Information Network Clinical Trial Registry (UMIN-CTR): UMIN000016146; Data of Registration: January 7, 2015. Electronic supplementary material The online version of this article (10.1186/s12872-018-0862-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Satoshi Higuchi
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan. .,Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-8611, Japan.
| | - Yusuke Kabeya
- Division of General Internal Medicine, Department of Internal Medicine, Tokai University, Isehara, Kanagawa, Japan.,Department of Home Care Medicine, Saiyu Clinic, Saitama, Japan
| | - Kenichi Matsushita
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan
| | - Keisei Tachibana
- Department of General Thoracic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Riken Kawachi
- Department of General Thoracic Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Hidefumi Takei
- Department of General Thoracic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Yutaka Suzuki
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Nobutsugu Abe
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Yorihisa Imanishi
- Department of Otorhinolaryngology, Head and Neck Surgery, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Kanagawa, Japan
| | - Kiyoshi Moriyama
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo, Japan
| | - Tomoko Yorozu
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo, Japan
| | - Koichiro Saito
- Department of Otolaryngology-Head and Neck Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Masanori Sugiyama
- Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Haruhiko Kondo
- Department of General Thoracic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Hideaki Yoshino
- Division of Cardiology, Department of Internal Medicine II, Kyorin University School of Medicine, Tokyo, Japan
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11
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Cebe L, Singh H. Reflex anoxic seizures (RAS) in an adult patient: a separate entity from epilepsy. BMJ Case Rep 2018; 2018:bcr-2017-222389. [PMID: 29739759 DOI: 10.1136/bcr-2017-222389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Reflex anoxic seizures (RAS) are essential in the differential diagnosis of non-epileptic paroxysmal seizures. They are precipitated by vagally mediated brief cardiac asystole, which in turn leads to transient cerebral ischaemia. RAS are usually seen in infants and preschool children, but in this case happened in a middle-aged man. Our patient is a 61-year-old man who presented with sudden, repeated contractions of his left upper arm and urine incontinence, followed by loss of consciousness for about 30 s. He reported a similar episode occurred 2 years earlier. He did indicate episodic confusion pointing towards possibility of more occurrences. In the emergency department, he developed a similar seizure, during which telemetry revealed sinus arrest lasted for 4-6 s that was followed by junctional escape. Implantation of a pacemaker resulted in total cessation of sinus arrest and seizure activity during the admission. On 1-year follow-up, patient and family members did not report episodic confusion or any seizure-like activity. RAS constitute a particular entity of seizures and need careful interpretation and management. They have a similar pathophysiology to cardiac syncope. Successful prevention of cerebral hypoperfusion with a cardiac pacemaker usually leads to complete resolution of symptoms in patients with RAS as demonstrated in this case.
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Affiliation(s)
- Laith Cebe
- Department of Internal Medicine, Allegiance Health, Jackson, Michigan, USA
| | - Harpreet Singh
- Department of Internal Medicine, Allegiance Health, Jackson, Michigan, USA.,Department of Osteopathic medicine, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan, USA
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12
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Wechselberger S, Piorkowski C, Pohl M. Current rare indications and future directions for implantable loop recorders. Herzschrittmacherther Elektrophysiol 2017; 27:366-370. [PMID: 27873022 DOI: 10.1007/s00399-016-0475-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The scope of application for implantable loop recorders has shifted away from the evaluation of unclear palpitations and syncope episodes to more complex conditions. This article focuses on rare indications of growing importance such as rhythm monitoring after ablation of atrial fibrillation or after cryptogenic stroke. Furthermore, forthcoming applications in various clinical settings are described, e. g., arrhythmia detection after myocardial infarction, after catheter-based valve interventions, in heart failure, and in cardiomyopathies. Enhancement of the capabilities of implantable loop recorders could broaden their fields of use.
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Affiliation(s)
- Simon Wechselberger
- Steinbeis Research Center on Electrophysiology and Cardiac Devices, Fetscherstraße 111, 01307, Dresden, Germany
| | - Christopher Piorkowski
- Steinbeis Research Center on Electrophysiology and Cardiac Devices, Fetscherstraße 111, 01307, Dresden, Germany.
- Department of Invasive Electrophysiology, Technical University of Dresden, Heart Center, University Hospital, Fetscherstraße 76, 01307, Dresden, Germany.
| | - Matthias Pohl
- Steinbeis Research Center on Electrophysiology and Cardiac Devices, Fetscherstraße 111, 01307, Dresden, Germany
- Department of Invasive Electrophysiology, Technical University of Dresden, Heart Center, University Hospital, Fetscherstraße 76, 01307, Dresden, Germany
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13
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Welton NJ, McAleenan A, Thom HHZ, Davies P, Hollingworth W, Higgins JPT, Okoli G, Sterne JAC, Feder G, Eaton D, Hingorani A, Fawsitt C, Lobban T, Bryden P, Richards A, Sofat R. Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis. Health Technol Assess 2017. [DOI: 10.3310/hta21290] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BackgroundAtrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources.ObjectivesTo conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model.DesignSystematic review, meta-analysis and cost-effectiveness analysis.SettingPrimary care.ParticipantsAdults.InterventionScreening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}.Main outcome measuresSensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening.Review methodsTwo reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies.ResultsDiagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.ConclusionsA national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.LimitationsMany inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability.Future workComparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population.Study registrationThis study is registered as PROSPERO CRD42014013739.FundingThe National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Nicky J Welton
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alexandra McAleenan
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Howard HZ Thom
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Philippa Davies
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Will Hollingworth
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Julian PT Higgins
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - George Okoli
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Jonathan AC Sterne
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Gene Feder
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | | | - Aroon Hingorani
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Christopher Fawsitt
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Trudie Lobban
- Atrial Fibrillation Association, Shipston on Stour, UK
- Arrythmia Alliance, Shipston on Stour, UK
| | - Peter Bryden
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alison Richards
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Reecha Sofat
- Division of Medicine, Faculty of Medical Science, University College London, London, UK
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14
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Korompoki E, Del Giudice A, Hillmann S, Malzahn U, Gladstone DJ, Heuschmann P, Veltkamp R. Cardiac monitoring for detection of atrial fibrillation after TIA: A systematic review and meta-analysis. Int J Stroke 2016; 12:33-45. [DOI: 10.1177/1747493016669885] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background and purpose The detection rate of atrial fibrillation has not been studied specifically in transient ischemic attack (TIA) patients although extrapolation from ischemic stroke may be inadequate. We conducted a systematic review and meta-analysis to determine the rate of newly diagnosed atrial fibrillation using different methods of ECG monitoring in TIA. Methods A comprehensive literature search was performed following a pre-specified protocol the PRISMA statement. Prospective observational studies and randomized controlled trials were considered that included TIA patients who underwent cardiac monitoring for >12 h. Primary outcome was frequency of detection of atrial fibrillation ≥30 s. Analyses of subgroups and of duration and type of monitoring were performed. Results Seventeen studies enrolling 1163 patients were included. The pooled atrial fibrillation detection rate for all methods was 4% (95% CI: 2–7%). Yield of monitoring was higher in selected (higher age, more extensive testing for arrhythmias before enrolment, or presumed cardioembolic/cryptogenic cause) than in unselected cohorts (7% vs 3%). Pooled mean atrial fibrillation detection rates rose with duration of monitoring: 4% (24 h), 5% (24 h to 7 days) and 6% (>7 days), respectively. Yield of non-invasive was significantly lower than that of invasive monitoring (4% vs. 11%). Significant heterogeneity was observed among studies (I2=60.61%). Conclusion This first meta-analysis of atrial fibrillation detection in TIA patients finds a lower atrial fibrillation detection rate in TIA than reported for IS and TIA cohorts in previous meta-analyses. Prospective studies are needed to determine actual prevalence of atrial fibrillation and optimal diagnostic procedure for atrial fibrillation detection in TIA.
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Affiliation(s)
- Eleni Korompoki
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - Angela Del Giudice
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - Steffi Hillmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Uwe Malzahn
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Clinical Trial Center, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - David J Gladstone
- Division of Neurology, Department of Medicine, University Toronto, Ontario, Canada
| | - Peter Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Clinical Trial Center, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
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15
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Imam YZ, D'Souza A, Malik RA, Shuaib A. Secondary Stroke Prevention: Improving Diagnosis and Management with Newer Technologies. Transl Stroke Res 2016; 7:458-477. [PMID: 27586681 DOI: 10.1007/s12975-016-0494-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 12/22/2022]
Abstract
Treatment of hypertension, diabetes, high cholesterol, smoking cessation, and healthy lifestyle have all contributed to the decline in the incidence of vascular disease over the last several decades. Patients who suffer an acute stroke are at a high risk for recurrence. Introduction of newer technologies and their wider use allows for better identification of patients in whom the risk of recurrence following an acute stroke may be very high. Traditionally, the major focus for diagnosis and management has focused on patient history, examination, imaging for carotid stenosis/occlusion, and detection of AF and paroxysmal AF (PAF) with 24-48 h cardiac monitoring. This review focuses on the usefulness of three newer investigative tools that are becoming widely available and lead to better prevention. Continuous ambulatory blood pressure measurements for 24 h or longer and 3D Doppler measures of the carotid arteries provide key useful information on the state of vascular health and enhance our ability to monitor the response to preventive therapies. Furthermore, the detection of PAF can be significantly improved with prolonged cardiac monitoring for 3 weeks or longer, enabling the initiation of appropriate prevention therapy. This review will focus on the potential impact and importance of these emerging technologies on the prevention of recurrent stroke in high-risk patients.
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Affiliation(s)
- Yahia Z Imam
- Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medicine in Qatar, Doha, Qatar
| | | | - Rayaz A Malik
- University of Manchester, Manchester, UK.,Weill Cornell Medicine in Qatar, Doha, Qatar
| | - Ashfaq Shuaib
- Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar. .,Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada.
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16
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Montalvo M, Ali R, Silver B, Khan M. Long-term Arrhythmia Monitoring in Cryptogenic Stroke: Who, How, and for How Long? Open Cardiovasc Med J 2016; 10:89-93. [PMID: 27347225 PMCID: PMC4897003 DOI: 10.2174/1874192401610010089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 10/08/2015] [Accepted: 11/25/2015] [Indexed: 11/22/2022] Open
Abstract
Cryptogenic stroke and transient ischemic attack (TIA) account for approximately one-third of stroke patients [1]. Paroxys-mal atrial fibrillation (PAF) has been suggested as a major etiology of these cryptogenic strokes [2, 3]. PAF can be difficult to diagnose because it is intermittent, often brief, and asymptomatic. PAF might be more prevalent than persistent atrial fibrillation in stroke and TIA patients, especially in younger populations [4, 5]. In patients with atrial fibrillation, anticoagulation provides significant risk reduction [6]. A new generation of oral anticoagulants has been approved for non-valvular atrial fibrillation, providing a variety of therapeutic options for patients with atrial fibrillation and risk of stroke [7]. Prior practice included an admission electrocardiogram (ECG) and continuous telemetry monitoring while in hospital [8]. However, this approach can lead to under-detection of brief asymptomatic events, which can occur at variable intervals, often outside of the hospital setting. Technological advancements have led to devices that can monitor cardiac rhythms outside of the hospital for longer durations resulting in higher yield of detection of atrial fibrillation events. Moreover, recent studies show that the normal monitoring time for arrhythmias may be shorter than ideal in order to detect atrial fibrillation, and increasing this interval could significantly improve detection of atrial fibrillation in these patients [9, 10]. The aim of this study is to review the literature in order to define what subgroup of patients, with what methodologies, and for how long monitoring for atrial fibrillation should occur in patients presenting with cryptogenic stroke.
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Affiliation(s)
- Mayra Montalvo
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, 96/79 13 Street, Boston, MA 02129, USA
| | - Rushna Ali
- Department of Neurosurgery, Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI 48202, USA
| | - Brian Silver
- Department of Neurology, Warren Alpert Medical School, Brown University, 110 Lockwood Street, Suite 324, Prov-idence, RI 02903, USA
| | - Muhib Khan
- Department of Neurology, Warren Alpert Medical School, Brown University, 110 Lockwood Street, Suite 324, Prov-idence, RI 02903, USA
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17
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Optimal Duration of Monitoring for Atrial Fibrillation in Cryptogenic Stroke: A Nonsystematic Review. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5704963. [PMID: 27314027 PMCID: PMC4903126 DOI: 10.1155/2016/5704963] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/21/2016] [Accepted: 05/03/2016] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) is the most common form of cardiac arrhythmias and an independent risk factor for stroke. Despite major advances in monitoring strategies, clinicians tend to miss the diagnoses of AF and especially paroxysmal AF due mainly to its asymptomatic presentation and the rather limited duration dedicated for monitoring for AF after a stroke, which is 24 hours as per the current recommended guidelines. Hence, determining the optimal duration of monitoring for paroxysmal atrial fibrillation after acute ischemic stroke remains a matter of debate. Multiple trials were published in regard to this matter using both invasive and noninvasive monitoring strategies for different monitoring periods. The data provided by these trials showcase strong evidence suggesting a longer monitoring strategy beyond 24 hours is associated with higher detection rates of AF, with the higher percentage of patients detected consequently receiving proper secondary stroke prevention with anticoagulation and thus justifying the cost-effectiveness of such measures. Overall, we thus conclude that increasing the monitoring duration for AF after a cryptogenic stroke to at least 72 hours will indeed enhance the detection rates, but the cost-effectiveness of this monitoring strategy compared to longer monitoring durations is yet to be established.
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18
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Ringwala SM, Tomson TT, Passman RS. Cardiac Monitoring for Atrial Fibrillation in Cryptogenic Stroke. Cardiol Clin 2016; 34:287-97. [DOI: 10.1016/j.ccl.2015.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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19
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Sangha RS, Bernstein R. Advances in the Detection and Monitoring of Atrial Fibrillation for Patients with Cryptogenic Ischemic Stroke. Curr Atheroscler Rep 2015; 17:71. [DOI: 10.1007/s11883-015-0544-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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AFZAL MUHAMMADR, GUNDA SAMPATH, WAHEED SALMAN, SEHAR NANDHINI, MAYBROOK RYANJ, DAWN BUDDHADEB, LAKKIREDDY DHANUNJAYA. Role of Outpatient Cardiac Rhythm Monitoring in Cryptogenic Stroke: A Systematic Review and Meta-Analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1236-45. [DOI: 10.1111/pace.12688] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/23/2015] [Accepted: 06/28/2015] [Indexed: 11/28/2022]
Affiliation(s)
- MUHAMMAD R. AFZAL
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - SAMPATH GUNDA
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - SALMAN WAHEED
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - NANDHINI SEHAR
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - RYAN J. MAYBROOK
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - BUDDHADEB DAWN
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
| | - DHANUNJAYA LAKKIREDDY
- From the Division of Cardiovascular Diseases; Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City Kansas
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21
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Favilla CG, Ingala E, Jara J, Fessler E, Cucchiara B, Messé SR, Mullen MT, Prasad A, Siegler J, Hutchinson MD, Kasner SE. Predictors of Finding Occult Atrial Fibrillation After Cryptogenic Stroke. Stroke 2015; 46:1210-5. [DOI: 10.1161/strokeaha.114.007763] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 01/20/2015] [Indexed: 12/27/2022]
Abstract
Background and Purpose—
Occult paroxysmal atrial fibrillation (AF) is found in a substantial minority of patients with cryptogenic stroke. Identifying reliable predictors of paroxysmal AF after cryptogenic stroke would allow clinicians to more effectively use outpatient cardiac monitoring and ultimately reduce secondary stroke burden.
Methods—
We analyzed a retrospective cohort of consecutive patients who underwent 28-day mobile cardiac outpatient telemetry after cryptogenic stroke or transient ischemic stroke. Univariate and multivariable analyses were performed to identify clinical, echocardiographic, and radiographic features associated with the detection of paroxysmal AF.
Results—
Of 227 patients with cryptogenic stroke (179) or transient ischemic stroke (48), 14% (95% confidence interval, 9%–18%) had AF detected on mobile cardiac outpatient telemetry, 58% of which was ≥30 seconds in duration. Age >60 years (odds ratio, 3.7; 95% confidence interval, 1.3–11) and prior cortical or cerebellar infarction seen on neuroimaging (odds ratio, 3.0; 95% confidence interval, 1.2–7.6) were independent predictors of AF. AF was detected in 33% of patients with both factors, but only 4% of patients with neither. No other clinical features (including demographics, CHA
2
DS
2
-VASc [combined stroke risk score: congestive heart failure, hypertension, age, diabetes, prior stroke/transient ischemic attack, vascular disease, sex] score, or stroke symptoms), echocardiographic findings (including left atrial size or ejection fraction), or radiographic characteristics of the acute infarction (including location, topology, or number) were associated with AF detection.
Conclusions—
Mobile cardiac outpatient telemetry detects AF in a substantial proportion of cryptogenic stroke patients. Age >60 years and radiographic evidence of prior cortical or cerebellar infarction are robust indicators of occult AF. Patients with neither had a low prevalence of AF.
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Affiliation(s)
- Christopher G. Favilla
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
| | - Erin Ingala
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
| | - Jenny Jara
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
| | - Emily Fessler
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
| | - Brett Cucchiara
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
| | - Steven R. Messé
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
| | - Michael T. Mullen
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
| | - Allyson Prasad
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
| | - James Siegler
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
| | - Mathew D. Hutchinson
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
| | - Scott E. Kasner
- From the Department of Neurology (C.G.F., E.I., J.J., E.F., B.C., S.R.M., M.T.M., J.S., S.E.K.) and Division of Cardiology, Department of Medicine (A.P., M.D.H.), University of Pennsylvania, Philadelphia
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Andrade JG, Field T, Khairy P. Detection of occult atrial fibrillation in patients with embolic stroke of uncertain source: a work in progress. Front Physiol 2015; 6:100. [PMID: 25883570 PMCID: PMC4381503 DOI: 10.3389/fphys.2015.00100] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/12/2015] [Indexed: 02/02/2023] Open
Abstract
Atrial fibrillation accounts for a substantial proportion of ischemic strokes of known etiology and may be responsible for an additional subset of the 25–40% of strokes of unknown cause (so-called cryptogenic). Oral anticoagulation is significantly more effective than antiplatelet therapy in the secondary prevention of atrial fibrillation-related strokes, providing justification for developing more sensitive approaches to detecting occult paroxysms of atrial fibrillation. In this article, we summarize the current state of knowledge regarding the value of in-hospital and out-patient monitoring for detecting atrial fibrillation in the context of cryptogenic stroke. We review the evidence for and against screening with standard Holter monitors, external loop recorders, the newer real-time continuous attended cardiac monitoring systems, cardiac implantable electronic devices, and insertable loop recorders. We review key questions regarding prolonged cardiac arrhythmia monitoring, including the relationship between duration of the atrial fibrillation episode and risk of thromboembolism, frequency of monitoring and its impact on the diagnostic yield in detecting occult or subclinical atrial fibrillation, and the temporal proximity of device-detected atrial fibrillation to stroke events. We conclude by proposing avenues for further research.
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Affiliation(s)
- Jason G Andrade
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal Montreal, QC, Canada ; Department of Medicine, Division of Cardiology, University of British Columbia Vancouver, BC, Canada
| | - Thalia Field
- Department of Medicine, Division of Neurology, University of British Columbia Vancouver, BC, Canada
| | - Paul Khairy
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal Montreal, QC, Canada
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Sposato LA, Cipriano LE, Saposnik G, Vargas ER, Riccio PM, Hachinski V. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2015; 14:377-87. [DOI: 10.1016/s1474-4422(15)70027-x] [Citation(s) in RCA: 387] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Yayehd K, Irles D, Akret C, Vadot W, Rodier G, Berremili T, Perenet S, Chevallier-Grenot M, Belle L, Dompnier A. Detection of paroxysmal atrial fibrillation by prolonged electrocardiographic recording after ischaemic stroke in patients aged<60years: a study with 21-day recording using the SpiderFlash(®) monitor. Arch Cardiovasc Dis 2015; 108:189-96. [PMID: 25669959 DOI: 10.1016/j.acvd.2014.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 09/26/2014] [Accepted: 11/26/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many studies have suggested that longer duration of cardiac monitoring is suitable for the detection of occult paroxysmal atrial fibrillation (AF) after stroke; however, most studies involved patients aged≥65years - a population with a high stroke rate. AIMS To assess the incidence of paroxysmal AF in unselected young patients presenting with stroke. METHODS We included consecutive patients aged<60years with a stroke diagnosis on magnetic resonance imaging. Aetiological screening included clinical history and examination, and biological and cardiac tests. Patients were included if they had no history of AF and if a 24-hour electrocardiogram recording detected no AF or atrial flutter. Patients wore the SpiderFlash(®) monitor for 21days after discharge from hospital. The primary outcome was detection of paroxysmal AF episodes lasting>30seconds during monitoring. The secondary outcome was detection of paroxysmal AF episodes lasting<30seconds and any arrhythmia during monitoring. RESULTS Among the 56 patients included (mean age 48±9years), 39 had cryptogenic stroke (CS) and 17 had stroke of known cause (SKC). Cardiac monitoring was achieved in 54 patients (37 CS, 17 SKC); one CS patient had a paroxysmal AF episode lasting>30seconds and one CS patient had a paroxysmal AF episode lasting<30seconds (versus no patients in the SKC group). Two CS patients and one SKC patient presented numerous premature atrial complexes. Non-sustained ventricular tachycardia was detected in one CS patient. CONCLUSION This prospective observational study showed a low rate of paroxysmal AF among young patients presenting with stroke, on the basis of 21-day cardiac monitoring. This result highlights the need to identify patients who would benefit from such long monitoring.
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Affiliation(s)
- Komlavi Yayehd
- Department of Cardiology, Campus University Teaching Hospital, Lomé, Togo
| | - Didier Irles
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | - Chrystelle Akret
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | - Wilfried Vadot
- Department of Neurology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | - Gilles Rodier
- Department of Neurology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | - Toufek Berremili
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | - Sophie Perenet
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
| | | | - Loïc Belle
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France.
| | - Antoine Dompnier
- Department of Cardiology, Annecy Hospital, Annecy, 74370 Metz-Tessy, France
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Dussault C, Toeg H, Nathan M, Wang ZJ, Roux JF, Secemsky E. Electrocardiographic monitoring for detecting atrial fibrillation after ischemic stroke or transient ischemic attack: systematic review and meta-analysis. Circ Arrhythm Electrophysiol 2015; 8:263-9. [PMID: 25639643 DOI: 10.1161/circep.114.002521] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/20/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a major cause of stroke. Although standard investigations after an event include electrocardiographic monitoring, the optimal duration to detect AF is unclear. We performed a systematic review and meta-analysis to determine whether the duration of electrocardiographic monitoring after an ischemic event is related to the detection of AF. METHODS AND RESULTS Prospective studies that reported the proportion of new AF diagnosed using electrocardiographic monitoring for > 12 hours in patients with recent stroke or transient ischemic attack were analyzed. Studies were excluded if the stroke was hemorrhagic or AF was previously diagnosed. A total of 31 articles met inclusion criteria. Longer duration of monitoring was associated with an increased detection of AF when examining monitoring time as a continuous variable (P < 0.001 for metaregression analysis). When dichotomizing studies based on monitoring duration, studies with monitoring lasting ≤ 72 hours detected AF in 5.1%, whereas monitoring lasting ≥ 7 days detected AF in 15%. The proportion of new diagnosis increased to 29.15% with extended monitoring for 3 months. Significant heterogeneity within studies was detected for both groups (≤ 72 hours, I(2) = 91.3%; ≥ 7 days, I(2) =7 5.8). When assessing the odds of AF detection in the 3 randomized controlled trial, there was a 7.26 increased odds of AF with long-term monitoring (95% confidence intervals [3.99-12.83]; P value < 0.001). CONCLUSIONS Longer duration of electrocardiographic monitoring after cryptogenic stroke is associated with a greater detection of AF. Future investigation is needed to determine the optimal duration of long-term monitoring.
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Affiliation(s)
- Charles Dussault
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.).
| | - Hadi Toeg
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Meena Nathan
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Zhi Jian Wang
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Jean-Francois Roux
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
| | - Eric Secemsky
- From the Division of Cardiac Electrophysiology, Department of Medicine, Sherbrooke University, Quebec, Canada (C.D., J.-F.R.); Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ontario, Canada (H.T.); Department of Cardiac Surgery, Boston Children's Hospital, MA (M.N.); Division of Cardiac Surgery, Anzhen Hospital, Department of Surgery, Capital Medical University, Beijing, China (Z.J.W.); and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston (E.S.)
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Diagnostic yield of external loop recording in patients with acute ischemic stroke or TIA. J Neurol 2015; 262:682-8. [DOI: 10.1007/s00415-014-7621-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 12/16/2014] [Accepted: 12/18/2014] [Indexed: 10/24/2022]
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PérezRodon J, FranciscoPascual J, RivasGándara N, RocaLuque I, Bellera N, MoyaMitjans À. Cryptogenic Stroke And Role Of Loop Recorder. J Atr Fibrillation 2014; 7:1178. [PMID: 27957141 DOI: 10.4022/jafib.1178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 12/12/2014] [Accepted: 12/21/2014] [Indexed: 12/29/2022]
Abstract
Ischemic stroke is an important cause of morbidity and mortality when untreated. Identifying atrial fibrillation is important because atrial fibrillation ischemic related strokes are associated with an increased risk of disability and death compared with strokes of other etiologies and tend to recur without anticoagulation. However, atrial fibrillation detection can be difficult when it is asymptomatic and paroxistic and may be the underlying cause of some cryptogenic strokes or strokes of unknown origin. In this review, the different methods of cardiac monitoring to detect atrial fibrillation in patients with cryptogenic stroke are summarized, with a focus on loop recorder monitoring.
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Affiliation(s)
- Jordi PérezRodon
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Jaume FranciscoPascual
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Nuria RivasGándara
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Ivo RocaLuque
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Neus Bellera
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
| | - Àngel MoyaMitjans
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Spain
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Gołąb-Janowska M, Meller A, Kotlęga D, Bajer-Czajkowska A, Nowacki P. Atrial fibrillation and stroke - Coexistence and attitude to preventive therapy on the basis of Szczecin and Szczecin region patients. Neurol Neurochir Pol 2014; 48:410-5. [PMID: 25482252 DOI: 10.1016/j.pjnns.2014.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 10/03/2014] [Accepted: 10/09/2014] [Indexed: 11/18/2022]
Abstract
Atrial fibrillation (AF) is an independent factor increasing the risk of an ischemic stroke (IS) fivefold. The objective of the study was to evaluate the frequency of coexistence of non-valvular AF and IS during the acute stroke and to analyze the attitude of AF patients to treatment. The study included 3712 successive patients presenting either an IS or a transient ischemic attack. The analysis revealed a significant increase in the rate of patients with AF and IS in the years 2010-2013 (31.9%) compared with 2002-2005 (20.2%). A rise in the proportion of AF and IS patients was recorded over the course of consecutive years in group II. The proportion of newly detected AF cases during hospital stay differed significantly between the groups (16.9% vs. 31.9%). Group I and II patients differed essentially with regards to hypertension incidence and female rates. Antiplatelet medications or OACs were taken by a significantly greater number of AF patients in group II. Low number of therapeutic levels of INR was recorded in both groups. IS and AF coexist more frequently than indicated by previous assessments and demographic data from other countries. Increase in the number of IS and AF patients may result from higher detectability of AF and older age of patients affected with stroke, women in particular. Despite a well grounded knowledge about the benefits of OACs use in the prophylaxis of thrombotic-embolic events in AF patients, they are rarely used. A surprisingly low proportion of patients taking OACs reaches a therapeutic INR level.
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Affiliation(s)
| | - Agnieszka Meller
- Department of Neurology, Pomeranian Medical University, Szczecin, Poland
| | - Dariusz Kotlęga
- Department of Neurology, Pomeranian Medical University, Szczecin, Poland
| | | | - Przemysław Nowacki
- Department of Neurology, Pomeranian Medical University, Szczecin, Poland
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Levin LA, Husberg M, Sobocinski PD, Kull VF, Friberg L, Rosenqvist M, Davidson T. A cost-effectiveness analysis of screening for silent atrial fibrillation after ischaemic stroke. Europace 2014; 17:207-14. [DOI: 10.1093/europace/euu213] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Ward F, McGovern R, Cotter PE. Troponin-I is a predictor of a delayed diagnosis of atrial fibrillation in acute ischemic stroke and transient ischemic attack. J Stroke Cerebrovasc Dis 2014; 24:66-72. [PMID: 25440352 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 07/28/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Prolonged cardiac monitoring detects higher rates of atrial fibrillation (AF) in ischemic stroke and transient ischemic attack (TIA) but is costly and has practical implications. The use of admission troponin-I (TnI) level to identify patients at high risk of delayed AF detection was investigated. METHODS Consecutive ischemic stroke and TIA cases presenting to our institute over a 13-month period were identified from the Irish Stroke and TIA Register. Electronic databases and case notes were examined. "Delayed" AF was diagnosed after a sinus rhythm admission electrocardiogram and no documented history. Group comparisons were made by AF status. The association between TnI and AF was investigated using a multivariate regression model. RESULTS A total of 185 cases (130 ischemic stroke) were analyzed. Mean age (standard deviation) was 73.3 (13.9) years, 47% female. Sixty-two cases (33.5%) had AF. The first documented presentation of AF was found in 21 cases, on admission electrocardiogram (n = 11) or inpatient telemetry (delayed, n = 10). TnI was higher in those with delayed AF than in those without AF (W = 194; P = .036). A higher proportion of those with an elevated TnI (30%) than those with a normal TnI (6.1%) had delayed diagnosis of AF (χ(2) = 6.41, P = .011). Having an abnormal TnI was a significant independent predictor of delayed AF detection (odds ratio, 5.8; P = .037). CONCLUSIONS TnI elevation is associated with a higher likelihood of subsequent AF diagnosis. Identification of these higher risk stroke and TIA cases for more intensive cardiac monitoring may improve stroke secondary prevention practices.
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Affiliation(s)
- Frank Ward
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland.
| | - Rory McGovern
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland
| | - Paul E Cotter
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland
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Características clínicas de pacientes llevados a monitoría externa de eventos. REVISTA COLOMBIANA DE CARDIOLOGÍA 2014. [DOI: 10.1016/j.rccar.2013.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Tieleman RG, Plantinga Y, Rinkes D, Bartels GL, Posma JL, Cator R, Hofman C, Houben RP. Validation and clinical use of a novel diagnostic device for screening of atrial fibrillation. Europace 2014; 16:1291-5. [PMID: 24825766 PMCID: PMC4149608 DOI: 10.1093/europace/euu057] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 02/25/2014] [Indexed: 11/19/2022] Open
Abstract
AIMS Patients with asymptomatic and undiagnosed atrial fibrillation (AF) are at increased risk of heart failure and ischaemic stroke. In this study, we validated a new diagnostic device, the MyDiagnostick, for detection of AF by general practitioners and patients. It records and stores a Lead I electrocardiogram (ECG) which is automatically analysed for the presence of AF. METHODS AND RESULTS In total, 192 patients (age 69.4 ± 12.6 years) were asked to hold the MyDiagnostick for 1 min, immediately before a routine 12-lead ECG was recorded. Atrial fibrillation detection and ECGs stored by the MyDiagnostick were compared with the cardiac rhythm on the 12-lead ECG. In a second part of the study, the MyDiagnostick was used to screen for AF during influenza vaccination in the general practitioner's office. Atrial fibrillation was present in 53 out of the 192 patients (27.6%). All AF patients were correctly detected by the MyDiagnostick (sensitivity 100%; 95% confidence interval 93-100%). MyDiagnostick AF classification in 6 out of 139 patients in sinus rhythm was considered false positive (specificity 95.9%; 95% confidence interval 91.3-98.1%). During 4 h of influenza vaccination in 676 patients (age 74 ± 7.1 years), the MyDiagnostick correctly diagnosed AF in all 55 patients (prevalence 8.1%). In 11 patients (1.6%), AF was not diagnosed before, all with a CHA2DS2VASc score of >1. CONCLUSION The high AF detection performance of the MyDiagnostick, combined with the ease of use of the device, enables large screening programmes for detection of undiagnosed AF.
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Affiliation(s)
- R G Tieleman
- Department of Cardiology, Martini Hospital Groningen, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - Y Plantinga
- Department of Cardiology, Martini Hospital Groningen, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - D Rinkes
- Department of Cardiology, Martini Hospital Groningen, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - G L Bartels
- Department of Cardiology, Martini Hospital Groningen, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - J L Posma
- Department of Cardiology, Martini Hospital Groningen, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - R Cator
- General Practitioners Molenweg, Haren, The Netherlands
| | - C Hofman
- General Practitioners Molenweg, Haren, The Netherlands
| | - R P Houben
- MyDiagnostick Medical BV, Maastricht, The Netherlands
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Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, Rymer MM, Thijs V, Rogers T, Beckers F, Lindborg K, Brachmann J. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370:2478-86. [PMID: 24963567 DOI: 10.1056/nejmoa1313600] [Citation(s) in RCA: 1427] [Impact Index Per Article: 142.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Current guidelines recommend at least 24 hours of electrocardiographic (ECG) monitoring after an ischemic stroke to rule out atrial fibrillation. However, the most effective duration and type of monitoring have not been established, and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40% of cases (cryptogenic stroke). Detection of atrial fibrillation after cryptogenic stroke has therapeutic implications. METHODS We conducted a randomized, controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor (ICM) is more effective than conventional follow-up (control) for detecting atrial fibrillation in patients with cryptogenic stroke. Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring underwent randomization within 90 days after the index event. The primary end point was the time to first detection of atrial fibrillation (lasting >30 seconds) within 6 months. Among the secondary end points was the time to first detection of atrial fibrillation within 12 months. Data were analyzed according to the intention-to-treat principle. RESULTS By 6 months, atrial fibrillation had been detected in 8.9% of patients in the ICM group (19 patients) versus 1.4% of patients in the control group (3 patients) (hazard ratio, 6.4; 95% confidence interval [CI], 1.9 to 21.7; P<0.001). By 12 months, atrial fibrillation had been detected in 12.4% of patients in the ICM group (29 patients) versus 2.0% of patients in the control group (4 patients) (hazard ratio, 7.3; 95% CI, 2.6 to 20.8; P<0.001). CONCLUSIONS ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke. (Funded by Medtronic; CRYSTAL AF ClinicalTrials.gov number, NCT00924638.).
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Affiliation(s)
- Tommaso Sanna
- From the Catholic University of the Sacred Heart, Institute of Cardiology (T.S.), and Institute of Neurology, Campus Bio-Medico University (V.D.L.) - both in Rome; the Department of Neurology and Stroke Center, University Hospital Essen, Essen (H.-C.D.), and Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg (J.B.) - both in Germany; Bluhm Cardiovascular Institute (R.S.P.) and Davee Department of Neurology (R.A.B.), Northwestern University Feinberg School of Medicine, Chicago; Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); University of Kansas Medical Center, Kansas City (M.M.R.); the KU Leuven Department of Neurosciences, the VIB-Vesalius Research Center, and the Department of Neurology, University Hospitals Leuven - all in Leuven, Belgium (V.T.); Medtronic, Mounds View, MN (T.R., K.L.); and Medtronic, Maastricht, the Netherlands (F.B.)
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Culebras A, Messé SR, Chaturvedi S, Kase CS, Gronseth G. Summary of evidence-based guideline update: prevention of stroke in nonvalvular atrial fibrillation: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2014; 82:716-24. [PMID: 24566225 DOI: 10.1212/wnl.0000000000000145] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To update the 1998 American Academy of Neurology practice parameter on stroke prevention in nonvalvular atrial fibrillation (NVAF). How often do various technologies identify previously undetected NVAF? Which therapies reduce ischemic stroke risk with the least risk of hemorrhage, including intracranial hemorrhage? The complete guideline on which this summary is based is available as an online data supplement to this article. METHODS Systematic literature review; modified Delphi process recommendation formulation. MAJOR CONCLUSIONS In patients with recent cryptogenic stroke, cardiac rhythm monitoring probably detects occult NVAF. In patients with NVAF, dabigatran, rivaroxaban, and apixaban are probably at least as effective as warfarin in preventing stroke and have a lower risk of intracranial hemorrhage. Triflusal plus acenocoumarol is likely more effective than acenocoumarol alone in reducing stroke risk. Clopidogrel plus aspirin is probably less effective than warfarin in preventing stroke and has a lower risk of intracranial bleeding. Clopidogrel plus aspirin as compared with aspirin alone probably reduces stroke risk but increases the risk of major hemorrhage. Apixaban is likely more effective than aspirin for decreasing stroke risk and has a bleeding risk similar to that of aspirin. MAJOR RECOMMENDATIONS Clinicians might obtain outpatient cardiac rhythm studies in patients with cryptogenic stroke to identify patients with occult NVAF (Level C) and should routinely offer anticoagulation to patients with NVAF and a history of TIA/stroke (Level B). Specific patient considerations will inform anticoagulant selection in patients with NVAF judged to need anticoagulation.
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Affiliation(s)
- Antonio Culebras
- From the Department of Neurology (A.C.), SUNY Upstate Medical University, Syracuse, NY; the Department of Stroke and Neurocritical Care (S.R.M.), Hospital of the University of Pennsylvania and the Pennsylvania Hospital, Philadelphia; the Stroke Program (S.C.), Wayne State University School of Medicine, Detroit, MI; the Department of Neurology (C.S.K.), Boston University School of Medicine and Boston Medical Center, Boston, MA; and the Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City, KS
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Bang OY, Ovbiagele B, Kim JS. Evaluation of Cryptogenic Stroke With Advanced Diagnostic Techniques. Stroke 2014; 45:1186-94. [DOI: 10.1161/strokeaha.113.003720] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Oh Young Bang
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
| | - Bruce Ovbiagele
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
| | - Jong S. Kim
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
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Rabinstein AA. Prolonged Cardiac Monitoring for Detection of Paroxysmal Atrial Fibrillation After Cerebral Ischemia. Stroke 2014; 45:1208-14. [DOI: 10.1161/strokeaha.113.003389] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Detection of paroxysmal atrial fibrillation or flutter in patients with acute ischemic stroke or transient ischemic attack by Holter monitoring. Indian Heart J 2014; 66:188-92. [PMID: 24814113 DOI: 10.1016/j.ihj.2014.02.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 07/16/2013] [Accepted: 02/05/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Paroxysmal atrial fibrillation and flutter are strong risk factors for stroke. Due to high recurrence rate of ischemic events and given the benefit of oral anticoagulation over antiplatelet drugs, it is important to identify this arrhythmia. Unfortunately, paroxysmal AF or flutter is asymptomatic in majority and therefore, difficult to detect. METHODS Consecutive patients presenting with symptoms of acute ischemic stroke or transient ischemic attack were included. All patients free of AF or flutter on presentation underwent 24 h Holter monitoring within 7 days of admission. RESULTS Overall, fifty two (52) patients (mean age 59.51 ± 13.45 years) with acute stroke (80.8%) and TIA (19.8%) underwent 24 h Holter monitoring. Paroxysmal AF was detected in 3 cases (5.8%), all 3 patients had acute stroke and were older than age 60 years. Type of stroke was the only factor which was associated with greater risk of having paroxysmal AF or flutter, AF accounted for 50% cases (2 out of 4) of clinically suspected cardio embolic stroke. CONCLUSION Screening consecutive patients with ischemic stroke with routine Holter monitoring will identify new atrial fibrillation/flutter in approximately one in 17 patients. Older age and type of stroke are strongly associated with increased risk. By carefully selecting the patients, the detection rates could be further increased.
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Schaefer JR, Leussler D, Rosin L, Pittrow D, Hepp T. Improved detection of paroxysmal atrial fibrillation utilizing a software-assisted electrocardiogram approach. PLoS One 2014; 9:e89328. [PMID: 24586692 PMCID: PMC3938451 DOI: 10.1371/journal.pone.0089328] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 01/19/2014] [Indexed: 12/12/2022] Open
Abstract
Background Automated complexity-based statistical stroke risk analysis (SRA) of electrocardiogram (ECG) recordings can be used to estimate the risk of paroxysmal atrial fibrillation (pAF). We investigated whether this method could improve the reliability of detection of patients at risk for pAF. Methods and Results Data from 12-lead ECGs, 24-h Holter ECGs, and SRA based on separate 1-hour Holter ECG snips were collected from three groups: 70 patients with a history of pAF but who showed no AF episode in the 12-lead ECG at study entry; 19 patients with chronic AF (at study entry); and 100 young healthy individuals. AF episodes were detected by Holter ECG in 19 of the 70 non-chronic AF patients (27.1% overall, 18.6% in the first hour), and 37 of these 70 patients were classified as at risk for pAF by SRA (representing a sensitivity of 52.9% based on the first hour of analyzed recording). Fifty-four of the 70 patients also showed a sinus rhythm in the first hour. SRA detected pAF risk in 23 of these 54 patients (representing a sensitivity of 42.6%). The Holter data showed at least 1 AF episode and at least 1 hour of sinus rhythm in nine of the patients with pAF. For these patients, SRA classified 77.8% as being at risk in the first hour after the end of the AF episode, and 71.4% and 42.9% as being at risk in the second and third hours, respectively. SRA detected almost all cardiologist-confirmed AF episodes that had been recorded in 1-hour ECG snips (sensitivity, 99.2%; specificity, 99.2%). Conclusions This outpatient study confirms previous findings that routine use of SRA could improve AF detection rates and thus may shorten the time between AF onset and initiation of prevention measures for patients at high risk for stroke.
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Affiliation(s)
- Jürgen R. Schaefer
- Department of Internal Medicine, Cardiology, Philipps-University, Marburg, Germany
- * E-mail:
| | - Dieter Leussler
- Cardiology Clinic, “Kardiologie Plattform Hessen”, Marburg, Germany
| | - Ludger Rosin
- Medical Department, Sanofi-Aventis, Berlin, Germany
| | - David Pittrow
- Institute for Clinical Pharmacology, Medical Faculty, Technical University Dresden, Dresden, Germany
| | - Thomas Hepp
- Apoplex Medical Technologies GmbH, Pirmasens, Germany
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AF Detected on Implanted Cardiac Implantable Electronic Devices: Is There a Threshold for Thromboembolic Risk? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:289. [PMID: 24500679 DOI: 10.1007/s11936-013-0289-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OPINION STATEMENT Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with elevated thromboembolism risk caused by multiple pathophysiologies, including a hypercoagulable state, structural heart changes, left atrial appendage stasis, inflammation, and endothelial dysfunction. With the exception of lone AF, most other categories of AF, whether paroxysmal or persistent, have been shown to share a high thromboembolism risk. Risk stratification schemes such as CHADS2 and CHA2DS2-VASc scores help to identify the level at which anticoagulation may mitigate thromboembolism risk. AF may be episodic and asymptomatic; therefore, AF diagnosis that depends entirely on office electrocardiogram (ECG) may be easily missed. With the increasing use of pacemakers, implantable cardioverter defibrillators (ICDs), and insertable loop recorders (ILRs) for diagnosis and treatment of arrhythmias, AF has been incidentally detected with increasing frequency. However, the sensitivity and specificity for detection of AF, especially brief episodes, vary from one type of device to another, and rhythm confirmation should be considered. Several recent studies have examined device-detected AF and have tried to follow associated clinical outcomes. In this paper, we review studies that have addressed device-detected AF and associated thromboembolism risk to try to identify the burden of AF that is associated with an elevated risk of thromboembolism and may therefore warrant anticoagulation therapy.
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Abdul-Rahim AH, Lees KR. Paroxysmal atrial fibrillation after ischemic stroke: how should we hunt for it? Expert Rev Cardiovasc Ther 2014; 11:485-94. [DOI: 10.1586/erc.13.21] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kishore A, Vail A, Majid A, Dawson J, Lees KR, Tyrrell PJ, Smith CJ. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke 2014; 45:520-6. [PMID: 24385275 DOI: 10.1161/strokeaha.113.003433] [Citation(s) in RCA: 257] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Atrial fibrillation (AF) confers a high risk of recurrent stroke, although detection methods and definitions of paroxysmal AF during screening vary. We therefore undertook a systematic review and meta-analysis to determine the frequency of newly detected AF using noninvasive or invasive cardiac monitoring after ischemic stroke or transient ischemic attack. METHODS Prospective observational studies or randomized controlled trials of patients with ischemic stroke, transient ischemic attack, or both, who underwent any cardiac monitoring for a minimum of 12 hours, were included after electronic searches of multiple databases. The primary outcome was detection of any new AF during the monitoring period. We prespecified subgroup analysis of selected (prescreened or cryptogenic) versus unselected patients and according to duration of monitoring. RESULTS A total of 32 studies were analyzed. The overall detection rate of any AF was 11.5% (95% confidence interval, 8.9%-14.3%), although the timing, duration, method of monitoring, and reporting of diagnostic criteria used for paroxysmal AF varied. Detection rates were higher in selected (13.4%; 95% confidence interval, 9.0%-18.4%) than in unselected patients (6.2%; 95% confidence interval, 4.4%-8.3%). There was substantial heterogeneity even within specified subgroups. CONCLUSIONS Detection of AF was highly variable, and the review was limited by small sample sizes and marked heterogeneity. Further studies are required to inform patient selection, optimal timing, methods, and duration of monitoring for detection of AF/paroxysmal AF.
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Affiliation(s)
- Amit Kishore
- From the Stroke and Vascular Research Centre, Institute of Cardiovascular Sciences (A.K., P.J.T., C.J.S.) and Centre for Biostatistics (A.V.), University of Manchester, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford, United Kingdom; Greater Manchester Comprehensive Stroke Centre, Department of Medical Neurosciences, Salford Royal Foundation Trust, Salford, United Kingdom (A.K., A.M., P.J.T., C.J.S.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Western Infirmary, Glasgow, United Kingdom (J.D., K.R.L.)
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Grond M, Jauss M, Hamann G, Stark E, Veltkamp R, Nabavi D, Horn M, Weimar C, Köhrmann M, Wachter R, Rosin L, Kirchhof P. Improved Detection of Silent Atrial Fibrillation Using 72-Hour Holter ECG in Patients With Ischemic Stroke. Stroke 2013; 44:3357-64. [DOI: 10.1161/strokeaha.113.001884] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background and Purpose—
Adequate diagnosis of atrial fibrillation (AF), including paroxysmal AF, is an important part of stroke workup. Prolonged ECG monitoring may improve the detection of paroxysmal, previously undiagnosed AF (unknown AF). Therefore, we evaluated systematic 72-hour Holter ECG monitoring to detect unknown AF for the workup of patients with stroke.
Methods—
Unselected survivors of a stroke or transient ischemic attack (TIA) without known AF were enrolled in a prospective, multicenter cohort study of 72-hour Holter ECG monitoring in 9 German secondary and tertiary stroke centers between May 2010 and January 2011. In addition to standardized workup of stroke pathogenesis according to the German Stroke Unit protocol, all patients underwent 72-hour Holter ECG monitoring directly after admission. All ECGs were centrally analyzed by 2 independent observers. We determined the proportion of unknown AF and compared the detection rates of 72- and 24-hour monitoring.
Results—
A total of 1135 patients were enrolled (mean age, 67 years [SD, 13.1 years], 45% women, 29% TIA). Unknown AF was detected in 49 out of 1135 patients (4.3%, [95% confidence interval, 3.4–5.2%]) by 72-hour ECG monitoring. Unknown AF was diagnosed in 29 patients (2.6%) within the first 24 hours of ECG monitoring, and in 20 more patients only by 72 hours of ECG monitoring. The number needed to screen by 72-hour ECG was 55 patients (95% confidence interval [35–123]) for each additional AF diagnosis. Patients with unknown AF were significantly older and had more often a history of previous stroke. Patients with unknown AF were equally distributed within categories of pathogenesis according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification.
Conclusions—
In unselected survivors of stroke or TIA, 72-hour ECG monitoring is feasible and improves the detection rate of silent paroxysmal AF.
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Affiliation(s)
- Martin Grond
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Marek Jauss
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Gerhard Hamann
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Erwin Stark
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Roland Veltkamp
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Darius Nabavi
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Markus Horn
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Christian Weimar
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Martin Köhrmann
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Rolf Wachter
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Ludger Rosin
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
| | - Paulus Kirchhof
- From the Department of Neurology, Kreisklinikum Siegen, Siegen, Germany (M.G.); Department of Neurology, Hainich Klinikum, Mühlhausen, Germany (M.J.); Department of Neurology, HSK Klinik, Wiesbaden, Germany (G.H.); Department of Neurology, Klinikum Offenbach, Offenbach, Germany (E.S.); Department of Neurology, University of Heidelberg, Germany (R.V.); Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany (D.N.); Department of Neurology, Klinikum Bad Hersfeld, Bad Hersfeld, Germany (M
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Suissa L, Lachaud S, Mahagne MH. Optimal Timing and Duration of Continuous Electrocardiographic Monitoring for Detecting Atrial Fibrillation in Stroke Patients. J Stroke Cerebrovasc Dis 2013; 22:991-5. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.01.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 11/30/2022] Open
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Cost-effectiveness of 7-day-Holter monitoring alone or in combination with transthoracic echocardiography in patients with cerebral ischemia. Clin Res Cardiol 2013; 102:875-84. [PMID: 23904073 PMCID: PMC3826055 DOI: 10.1007/s00392-013-0601-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 07/17/2013] [Indexed: 11/25/2022]
Abstract
Background and purpose
Prolonged Holter monitoring of patients with cerebral ischemia increases the detection rate of paroxysmal atrial fibrillation (PAF); this leads to improved antithrombotic regimens aimed at preventing recurrent ischemic strokes. The aim of this study was to compare a 7-day-Holter monitoring (7-d-Holter) alone or in combination with prior selection via transthoracic echocardiography (TTE) to a standard 24-h-Holter using a cost-utility analysis. Methods Lifetime cost, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICER) were estimated for a cohort of patients with acute cerebral ischemia and no contraindication to oral anticoagulation. A Markov model was developed to simulate the long-term course and progression of cerebral ischemia considering the different diagnostic algorithms (24-h-Holter, 7-d-Holter, 7-d-Holter after preselection by TTE). Clinical data for these algorithms were derived from the prospective observational Find-AF study (ISRCTN 46104198). Results Predicted lifelong discounted costs were 33,837 € for patients diagnosed by the 7-d-Holter and 33,852 € by the standard 24-h-Holter. Cumulated QALYs were 3.868 for the 7-d-Holter compared to 3.844 for the 24-h-Holter. The 7-d-Holter dominated the 24-h-Holter in the base-case scenario and remained cost-effective in extensive sensitivity analysis of key input parameter with a maximum of 8,354 €/QALY gained. Preselecting patients for the 7-d-Holter had no positive effect on the cost-effectiveness. Conclusions A 7-d-Holter to detect PAF in patients with cerebral ischemia is cost-effective. It increases the detection which leads to improved antithrombotic regimens; therefore, it avoids recurrent strokes, saves future costs, and decreases quality of life impairment. Preselecting patients by TTE does not improve cost-effectiveness.
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Garg AK, Paul SP. Reflex anoxic seizures are not epileptic fits: a management dilemma. Indian J Pediatr 2013; 80:531-3. [PMID: 23271312 DOI: 10.1007/s12098-012-0953-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 12/14/2012] [Indexed: 11/28/2022]
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Detection of paroxysmal atrial fibrillation in stroke/tia patients. Stroke Res Treat 2013; 2013:840265. [PMID: 23662246 PMCID: PMC3622405 DOI: 10.1155/2013/840265] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 03/04/2013] [Indexed: 12/11/2022] Open
Abstract
One-third of stroke and transient ischemic attack (TIA) are cryptogenic, and paroxysmal atrial fibrillation (PAF) has been suggested as a possible cause for these cryptogenic strokes. Multiple studies have recently evaluated long-term cardiac rhythm monitoring with good yield for PAF. The duration of monitoring varies between studies as well as the qualifying event definition. Moreover, the clinical significance of very brief atrial fibrillation events is unclear in the literature. This paper provides an overview of current advances in the detection of paroxysmal atrial fibrillation, the clinical and genetic factors predictive of arrhythmia detection, and the therapeutic dilemma concerning this approach.
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McManus DD, Lee J, Maitas O, Esa N, Pidikiti R, Carlucci A, Harrington J, Mick E, Chon KH. A novel application for the detection of an irregular pulse using an iPhone 4S in patients with atrial fibrillation. Heart Rhythm 2013; 10:315-9. [PMID: 23220686 PMCID: PMC3698570 DOI: 10.1016/j.hrthm.2012.12.001] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is common and associated with adverse health outcomes. Timely detection of AF can be challenging using traditional diagnostic tools. Smartphone use is increasing and may provide an inexpensive and user-friendly means to diagnoseAF. OBJECTIVE To test the hypothesis that a smartphone-based application could detect an irregular pulse fromAF. METHODS Seventy-six adults with persistent AF were consented for participation in our study. We obtained pulsatile time series recordings before and after cardioversion using an iPhone 4S camera. A novel smartphone application conducted real-time pulse analysis using 2 statistical methods: root mean square of successive RR difference (RMSSD/mean) and Shannon entropy (ShE). We examined the sensitivity, specificity, and predictive accuracy of both algorithms using the 12-lead electrocardiogram as the gold standard. RESULTS RMSDD/mean and ShE were higher in participants in AF than in those with sinus rhythm. The 2 methods were inversely related to AF in regression models adjusting for key factors including heart rate and blood pressure (beta coefficients per SD increment in RMSDD/mean and ShE were-0.20 and-0.35; P<.001). An algorithm combining the 2 statistical methods demonstrated excellent sensitivity (0.962), specificity (0.975), and accuracy (0.968) for beat-to-beat discrimination of an irregular pulse during AF from sinus rhythm. CONCLUSIONS In a prospectively recruited cohort of 76 participants undergoing cardioversion for AF, we found that a novel algorithm analyzing signals recorded using an iPhone 4S accurately distinguished pulse recordings during AF from sinus rhythm. Data are needed to explore the performance and acceptability of smartphone-based applications for AF detection.
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Affiliation(s)
- David D McManus
- Cardiac Electrophysiology Section, Cardiovascular Medicine Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA.
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Heart rhythm in 90+years old fallers. Eur Geriatr Med 2013. [DOI: 10.1016/j.eurger.2012.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Miller DJ, Khan MA, Schultz LR, Simpson JR, Katramados AM, Russman AN, Mitsias PD. Outpatient cardiac telemetry detects a high rate of atrial fibrillation in cryptogenic stroke. J Neurol Sci 2013; 324:57-61. [PMID: 23102659 DOI: 10.1016/j.jns.2012.10.001] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 09/11/2012] [Accepted: 10/04/2012] [Indexed: 11/16/2022]
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