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Lasek-Bal A, Konka A, Puz P, Boidol J, Kosarz-Lanczek K, Puz A, Wagner-Kusz A, Tomasik A, Student S. The Usefulness of Outpatient Cardiac Telemetry in Patients with Cryptogenic Stroke. J Clin Med 2024; 13:3819. [PMID: 38999384 PMCID: PMC11242364 DOI: 10.3390/jcm13133819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/10/2024] [Accepted: 06/18/2024] [Indexed: 07/14/2024] Open
Abstract
Introduction: Atrial fibrillation (AF), apart from non-stenotic supracardiac atherosclerosis and neoplastic disease, is the leading cause of cryptogenic stroke, including embolic stroke of un-determined source (ESUS). The aim of our study was to determine the prevalence of AF in ESUS patients based on 30-day telemetric heart rate monitoring initiated within three months after stroke onset. Another aim was to identify factors that increase the likelihood of detecting subsequent AF among ESUS patients. Material and Methods: patients with first-ever stroke classified as per the ESUS definition were eligible for this study. All patients underwent outpatient 30-day telemetric heart rate monitoring. Results: In the period between 2020 and 2022, 145 patients were included. The mean age of all qualified patients was 54; 40% of eligible patients were female. Six patients (4.14%), mostly male patients (4 vs. 2), were diagnosed with AF within the study period. In each case, the diagnosis related to a patient whose stroke occurred in the course of large vessel occlusion. Episodes of AF were detected between day 1 and 25 after starting ECG monitoring. Out of the analyzed parameters that increase the probability of, A.F.; only supraventricular extrasystoles proved to be an independent factor regarding an increased risk of AF [OR 1.046, CI 95% 1.016-1.071, p-value < 0.01]. Conclusions: The use of telemetry heart rhythm monitoring in an outpatient setting can detect AF in 4% of ESUS patients who have undergone prior diagnostic procedures for cardiogenic embolism. Supraventricular extrasystoles significantly increases the likelihood of AF detection in patients with ESUS within three months following stroke. Comorbid coronary artery disease, diabetes and hypertension, rather than a single-factor clinical burden, increase the likelihood of AF detection in older ESUS patients. ESUS in the course of large vessel occlusion is probably associated with an increased likelihood of cardiogenic embolism.
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Affiliation(s)
- Anetta Lasek-Bal
- Department of Neurology, School of Health Sciences, Medical University of Silesia in Katowice, 40-055 Katowice, Poland
- Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-055 Katowice, Poland; (K.K.-L.)
| | - Adam Konka
- Silesian Park of Medical Technology Kardio-Med Silesia, 42-800 Zabrze, Poland; (A.K.); (A.T.)
| | - Przemysław Puz
- Department of Neurology, School of Health Sciences, Medical University of Silesia in Katowice, 40-055 Katowice, Poland
- Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-055 Katowice, Poland; (K.K.-L.)
| | - Joanna Boidol
- Silesian Park of Medical Technology Kardio-Med Silesia, 42-800 Zabrze, Poland; (A.K.); (A.T.)
- 1st Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
| | - Katarzyna Kosarz-Lanczek
- Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-055 Katowice, Poland; (K.K.-L.)
| | - Agnieszka Puz
- Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-055 Katowice, Poland; (K.K.-L.)
| | - Anna Wagner-Kusz
- Department of Neurology, School of Health Sciences, Medical University of Silesia in Katowice, 40-055 Katowice, Poland
- Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, 40-055 Katowice, Poland; (K.K.-L.)
| | - Andrzej Tomasik
- Silesian Park of Medical Technology Kardio-Med Silesia, 42-800 Zabrze, Poland; (A.K.); (A.T.)
- 2nd Department of Cardiology in Zabrze, Faculty of Medical Sciences in Zabrze, Medical University of Silesia in Katowice, 40-055 Katowice, Poland
| | - Sebastian Student
- Faculty of Automatic Control, Electronics and Computer Science, Silesian University of Technology, 44-100 Gliwice, Poland;
- Biotechnology Center, Silesian University of Technology, 44-100 Gliwice, Poland
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Devos P, Guedeney P, Montalescot G. Patent Foramen Ovale Percutaneous Closure: Evolution and Ongoing Challenges. J Clin Med 2023; 13:54. [PMID: 38202061 PMCID: PMC10780039 DOI: 10.3390/jcm13010054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/28/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Patent foramen ovale (PFO) concerns nearly a quarter of the general population and incidence may reach up to 50% in patients with cryptogenic stroke. Recent randomized clinical trials confirmed that percutaneous closure of PFO-related stroke reduces the risk of embolic event recurrence. PFO also comes into play in other pathogenic conditions, such as migraine, decompression sickness or platypnea-orthodeoxia syndrome, where the heterogeneity of patients is high and evidence for closure is less well-documented. In this review, we describe the current indications for PFO percutaneous closure and the remaining challenges, and try to provide future directions regarding the technique and its indications.
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Affiliation(s)
- Perrine Devos
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Paul Guedeney
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Gilles Montalescot
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
- Institut de Cardiologie, Centre Hospitalier Universitaire, Pitié-Salpêtrière, 47 Boulevard de l’Hôpital, 75013 Paris, France
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3
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de Gregorio C, Di Franco A, Panno AV, Di Franco M, Scaccianoce G, Campanella F, Novo G, Galassi AR, Novo S. Subclinical Atrial Fibrillation on Prolonged ECG Holter Monitoring: Results from the Multicenter Real-World SAFARI (Silent Atrial Fibrillation ANCE-Sicily Research Initiative) Study. J Cardiovasc Dev Dis 2023; 10:336. [PMID: 37623349 PMCID: PMC10455667 DOI: 10.3390/jcdd10080336] [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: 07/01/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND The detection of subclinical/silent atrial fibrillation (SAF) in the general population is of the utmost importance, given its potential adverse consequences. Incident AF has been observed in 30% to 70% of patients with implanted devices, but its prevalence may indeed be lower in the general population. The prospective, multicentric, observational Silent Atrial Fibrillation ANCE Research Initiative (SAFARI) study aimed at assessing the SAF prevalence in a real-world outpatient setting by the means of a small, wearable, prolonged ECG Holter monitoring (>5 days) device (CGM HI 3-Lead ECG; CGM TELEMEDICINE, Piacenza, Italy). METHODS Patients ≥ 55 years of age at risk for AF were screened according to the inclusion criteria to undergo prolonged 3-lead ECG Holter monitoring. SAF episodes were classified as follows: Class A, <30 s; Class B, 30 to 299 s; and Class C, ≥300 s. RESULTS In total, 119 patients were enrolled (64 men; median age 71 (IQR 55-85) years). At a median of 13.5 (IQR 5-21) days of monitoring, SAF episodes were found in 19 patients (16%). A total of 10,552 arrhythmic episodes were registered, 6901 in Class A (n = 7 patients), 2927 in Class B (n = 3), and 724 in Class C (n = 9), (Class A vs. B and C, p < 0.001). This latter group had multiple (all-class) episodes, and two patients had >1000 episodes. There were no clinical, echocardiographic, or laboratory findings able to discriminate patients with SAF from those in sinus rhythm in univariate and multivariable analyses; of note is that the Class C patients showed a higher diastolic blood pressure, resting heart rate, and indexed LA volume. CONCLUSIONS Over a median of 13 days of Holter monitoring, the SAFARI study confirmed the usefulness of small wearable devices in detecting SAF episodes in real-world outpatients at risk for, but with no prior history of, AF.
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Affiliation(s)
- Cesare de Gregorio
- Department of Clinical and Experimental Medicine, Cardiology Unit, University Hospital of Messina, 98122 Messina, Italy
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10065, USA;
| | | | | | | | - Francesca Campanella
- Department of Clinical and Experimental Medicine, Cardiology Unit, University Hospital of Messina, 98122 Messina, Italy
| | - Giuseppina Novo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Division of Cardiology, University of Palermo, 90133 Palermo, Italy; (G.N.); (A.R.G.); (S.N.)
| | - Alfredo Ruggero Galassi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Division of Cardiology, University of Palermo, 90133 Palermo, Italy; (G.N.); (A.R.G.); (S.N.)
| | - Salvatore Novo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Division of Cardiology, University of Palermo, 90133 Palermo, Italy; (G.N.); (A.R.G.); (S.N.)
| | - the SAFARI Study Group
- Department of Clinical and Experimental Medicine, Cardiology Unit, University Hospital of Messina, 98122 Messina, Italy
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Abstract
INTRODUCTION Stroke is one of the leading causes of mortality and morbidity globally. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is set to reach epidemic proportions. AF is associated with a five-fold increase in risk of stroke. Strokes caused by AF more often are fatal or result in severe disability. Even though the incidence of stroke has been significantly reduced by oral anticoagulation, AF is thought to account for a significant proportion of cryptogenic strokes where no etiology is identified. AREAS COVERED This article reviews the literature related to AF and stroke, pathophysiological insights, diagnosis of AF in stroke patients, and its management (Graphical Abstract). EXPERT OPINION The pathophysiology of thrombogenesis that links AF and stroke is not well understood and is an area of active research to identify new therapeutic targets to prevent AF and stroke. As the nature of AF and stroke is multifaceted, an integrated care approach to managing AF and stroke is increasingly essential.
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Affiliation(s)
- Sylvia E Choi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
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5
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Sharma AN, McIntyre WF, Nguyen ST, Baranchuk A. Implantable loop recorders in patients with atrial fibrillation. Expert Rev Cardiovasc Ther 2022; 20:919-928. [PMID: 36444859 DOI: 10.1080/14779072.2022.2153673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Implantable loop recorders (ILRs) provide practitioners with high-quality electrocardiographic data over an extended monitoring period. These data can guide the diagnosis and management of patients with atrial fibrillation (AF). AREAS COVERED This review summarizes the available evidence and consensus statements supporting the use of ILRs in the detection of AF, as well as monitoring of patients with known AF. Future directions for research are also discussed. EXPERT OPINION ILRs are the gold standard for detecting AF, providing superior diagnostic yield compared to other modes of ambulatory electrocardiography monitoring. Both experimental evidence and consensus statements support the use of ILRs in clinical settings where the diagnosis of AF may significantly change management, or where a high degree of sensitivity is needed. ILRs may also be used to monitor patients following AF ablation. More evidence is needed to better inform how ILR-detected AF should change management.
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Affiliation(s)
- Arjun N Sharma
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, ON, Canada
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6
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Carrington M, Providência R, Chahal CAA, Ricci F, Epstein AE, Gallina S, Fedorowski A, Sutton R, Khanji MY. Clinical applications of heart rhythm monitoring tools in symptomatic patients and for screening in high-risk groups. Europace 2022; 24:1721-1729. [PMID: 35983729 DOI: 10.1093/europace/euac088] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/12/2022] [Indexed: 12/15/2022] Open
Abstract
Recent technological advances have facilitated and diversified the options available for the diagnosis of cardiac arrhythmias. Ranging from simple resting or exercise electrocardiograms to more sophisticated and expensive smartphones and implantable cardiac monitors. These tests and devices may be used for varying periods of time depending on symptom frequency. The choice of the most appropriate heart rhythm test should be guided by clinical evaluation and optimized following accurate characterization of underlying symptoms, 'red flags', risk factors, and consideration of cost-effectiveness of the different tests. This review provides evidence-based guidance for assessing suspected arrhythmia in patients who present with symptoms or in the context of screening, such as atrial fibrillation or advanced conduction disturbances following transcatheter aortic valve implantation in high-risk groups. This is intended to help clinicians choose the most appropriate diagnostic tool to facilitate the management of patients with suspected arrhythmias.
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Affiliation(s)
- Mafalda Carrington
- Department of Cardiology, Hospital do Espírito Santo de Évora, Évora, Portugal
| | - Rui Providência
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Department of Cardiology, Newham University Hospital, BartsHealth NHS Trust, London, UK.,Institute of Health Informatics Research, University College London, London, UK
| | - C Anwar A Chahal
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Cardiovascular Division, University of Pennsylvania, Philadelphia, PA, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy.,Department of Cardiology, Casa di Cura Villa Serena, Città Sant'Angelo, Italy.,Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden
| | - Andrew E Epstein
- Cardiovascular Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Artur Fedorowski
- Department of Cardiology, Casa di Cura Villa Serena, Città Sant'Angelo, Italy.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Lund University, 205 02 Malmö, Sweden.,Department of Cardiology, Hammersmith Hospital Campus, Imperial College, London, UK
| | - Mohammed Y Khanji
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK.,Department of Cardiology, Newham University Hospital, BartsHealth NHS Trust, London, UK.,NIHR Biomedical Research Unit, William Harvey Research Institute, Queen Mary University of London, London, UK
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7
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Ratajczak-Tretel B, Tancin Lambert A, Al-Ani R, Arntzen K, Bakkejord GK, Bekkeseth HMO, Bjerkeli V, Eldøen G, Gulsvik A, Halvorsen B, Høie GA, Ihle-Hansen H, Ihle-Hansen H, Ingebrigtsen S, Johansen H, Kremer C, Krogseth SB, Kruuse C, Kurz M, Nakstad I, Novotny V, Næss H, Qazi R, Rezaj MK, Rørholt DM, Steffensen LH, Sømark J, Tobro H, Truelsen TC, Wassvik L, Ægidius KL, Atar D, Aamodt AH. Atrial fibrillation in cryptogenic stroke and TIA patients in the nordic atrial fibrillation and stroke The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Main results. Eur Stroke J 2022; 8:148-156. [PMID: 37021182 PMCID: PMC10069172 DOI: 10.1177/23969873221123122] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians. Patients and methods: Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection. Results: ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p < 0.001), had higher pre-stroke CHA₂DS₂-VASc score (median 3 vs 2; p < 0.001) and admission NIHSS (median 2 vs 1; p = 0.001); and more often hypertension ( p = 0.045) and dyslipidaemia ( p = 0.005) than non-AF patients. The arrhythmia was recurrent in 91.9% and asymptomatic in 93.2%. At 12-month follow-up anticoagulants usage was 97.3%. Discussion and conclusions: ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units.
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Affiliation(s)
- B Ratajczak-Tretel
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - A Tancin Lambert
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - R Al-Ani
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - K Arntzen
- Department for Neurology, Nordlandssykehuset, Bodø, Norway
| | - GK Bakkejord
- Department for Neurology, Nordlandssykehuset, Bodø, Norway
| | - HMO Bekkeseth
- Department of Neurology, Lillehammer Hospital, Innlandet Hospital Trust, Lillehammer, Norway
| | - V Bjerkeli
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - G Eldøen
- Department of Neurology, Molde Hospital, Molde, Norway
| | - A Gulsvik
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - B Halvorsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - GA Høie
- Department of Cardiology, Østfold Hospital Trust, Grålum, Norway
| | - H Ihle-Hansen
- Ullevål, Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - H Ihle-Hansen
- Department of Internal Medicine, Vestre Viken Hospital Trust, Bærum Hospital, Gjettum, Norway
| | - S Ingebrigtsen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - H Johansen
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - C Kremer
- Department of Neurology, Department of Clinical Sciences Lund University, Skåne University Hospital, Malmö, Sweden
| | - SB Krogseth
- Department of Neurology, Vestfold Hospital, Tønsberg, Norway
| | - C Kruuse
- Department of Neurology, Herlev Gentofte Hospital, Herlev, Denmark
| | - M Kurz
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - I Nakstad
- Department of Neurology, Vestre Viken Hospital Trust, Drammen Hospital, Drammen, Norway
| | - V Novotny
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - H Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - R Qazi
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - MK Rezaj
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - DM Rørholt
- Department of Neurology, Molde Hospital, Molde, Norway
| | - LH Steffensen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - J Sømark
- Department of Neurology, Lillehammer Hospital, Innlandet Hospital Trust, Lillehammer, Norway
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - H Tobro
- Department of Neurology, Telemark Hospital, Skien, Norway
| | - TC Truelsen
- Department of Neurology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - L Wassvik
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - KL Ægidius
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - D Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - AH Aamodt
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of neuromedicine and movement science, the Norwegian University of Science and Technology, Trondheim, Norway
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8
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Swale M, Paul V, Delacroix S, Young G, McSpadden L, Ryu K, Di Fiore D, Santos M, Tan I, Conradie A, Duong M, Schwarz N, Worthley S, Pavia S. Changes in R-wave amplitude at implantation are associated with gender and orientation of insertable cardiac monitor: observations from the confirm Rx™ body posture and physical activity study. BMC Cardiovasc Disord 2022; 22:439. [PMID: 36209063 PMCID: PMC9548115 DOI: 10.1186/s12872-022-02752-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Insertable cardiac monitors (ICMs) are small subcutaneously implanted devices that detect changes in R-wave amplitudes (RWAs), effective in arrhythmia-monitoring. Although ICMs have proven to be immensely successful, electrical artefacts are frequent and can lead to misdiagnosis. Thus, there is a growing need to sustain and increase efficacy in detection rates by gaining insight into various patient-specific factors such as body postures and activities. Methods RWAs were measured in 15 separate postures, including supine, lying on the right-side (RS) or left-side (LS) and sitting, and two separate ICM orientations, immediately after implantation of Confirm Rx™ ICM in 99 patients. Results The patients (53 females and 46 males, mean ages 66.62 ± 14.7 and 66.40 ± 12.25 years, respectively) had attenuated RWAs in RS, LS and sitting by ~ 26.4%, ~ 27.8% and ~ 21.2% respectively, compared to supine. Gender-based analysis indicated RWAs in RS (0.32 mV (0.09–1.03 mV), p < 0.0001) and LS (0.37 mV (0.11–1.03 mV), p = 0.004) to be significantly attenuated compared to supine (0.52 mV (0.20–1.03 mV) for female participants. Similar attenuation was not evident for male participants. Further, parasternally oriented ICMs (n = 44), attenuated RWAs in RS (0.37 mV(0.09–1.03 mV), p = 0.05) and LS (0.34 mV (0.11–1.03 mV), p = 0.02) compared to supine (0.48 mV (0.09–1.03 mV). Similar differences were not observed in participants with ICMs in the 45°-relative-to-sternum (n = 46) orientation. When assessing the combined effect of gender and ICM orientation, female participants demonstrated plausible attenuation in RWAs for RS and LS postures compared to supine, an effect not observed in male participants. Conclusion This is the first known study depicting the effects on RWA due to body postures and activities immediately post-implantation with an overt impact by gender and orientation of ICM. Future work assessing the cause of gender-based differences in RWAs may be critical. Trial registration: Clinical Trials, NCT03803969. Registered 15 January 2019 – Retrospectively registered, https://clinicaltrials.gov/NCT03803969
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Affiliation(s)
- Matthew Swale
- The Valley Private Hospital, Mulgrave, VIC, Australia
| | - Vincent Paul
- St. John of God Murdoch Hospital, Murdoch, WA, Australia
| | - Sinny Delacroix
- Abbott, Sylmar, CA, USA. .,GenesisCare, Leabrook, 284 Kensington Road, Leabrook, SA, Australia.
| | - Glenn Young
- St. Andrew's Hospital, Adelaide, SA, Australia
| | | | | | - David Di Fiore
- Friendly Society Private Hospital, Bundaberg, QLD, Australia
| | | | | | - Andre Conradie
- Friendly Society Private Hospital, Bundaberg, QLD, Australia
| | - MyNgan Duong
- GenesisCare, Leabrook, 284 Kensington Road, Leabrook, SA, Australia
| | - Nisha Schwarz
- GenesisCare, Leabrook, 284 Kensington Road, Leabrook, SA, Australia
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9
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Del Buono MG, Sanna T. Atrial fibrillation: focus on monitoring strategies after cryptogenic stroke. Minerva Cardiol Angiol 2022; 70:606-615. [PMID: 35080356 DOI: 10.23736/s2724-5683.21.05851-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes, with stroke potentially being the first manifestation of a previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic events, searching for unknown AF after stroke requires a comprehensive diagnostic workup. Prospective data have demonstrated the benefits of long-term cardiac monitoring to identify AF in association with cryptogenic stroke, as most strokes are presumed to result from AF. However, strategies of empirical anticoagulation using oral anticoagulants following cryptogenic stroke failed to improve outcomes. We herein summarize contemporary evidence and knowledge gaps on searching for AF after a stroke and the potential secondary prevention strategies to prevent further recurrences.
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Affiliation(s)
| | - Tommaso Sanna
- Sacred Heart Catholic University, Rome, Italy -
- IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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10
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Jiang H, Tan SY, Wang JK, Li J, Tu TM, Tan VH, Yeo C. A meta-analysis of extended ECG monitoring in detection of atrial fibrillation in patients with cryptogenic stroke. Open Heart 2022; 9:openhrt-2022-002081. [PMID: 36175044 PMCID: PMC9528717 DOI: 10.1136/openhrt-2022-002081] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Objective The aim of this systematic review is to evaluate the various modalities available for extended ECG monitoring in the detection of atrial fibrillation (AF) following a cryptogenic stroke. Methods MEDLINE (Ovid), EMBASE (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL) were searched from January 2011 to November 2021. All randomised controlled trials and prospective cohort studies including the use of extended ECG monitoring >24 hours with a minimum duration of AF of 30 s in patients with either cryptogenic strokes or transient ischaemic attacks were included. A random-effects model was used to pool effect estimates of AF detection rates from different ECG modalities. Results 3924 studies were identified, of which 47 were included reporting on a pooled population of 6448 patients with cryptogenic stroke. The pooled AF rate for implantable loop recorders (ILRs) increased from 4.9% (3.0%–7.9%) at 1 month to 38.4% (20.4%–60.2%) at 36 months. Mobile cardiac outpatient telemetry (MCOT) had a significantly higher pooled AF detection rate of 12.8% (8.9%–17.9%) versus 4.9% (3.0%–7.9%) for ILR at 1 month (p<0.0001). Predictors for AF detection include duration of monitoring (p<0.0001) and age (p<0.0001) for ILRs, but only age for MCOTs (p<0.020). Conclusion MCOT has a higher rate of detection at 1 month and is less invasive. Beyond 1 month, compliance becomes a significant limitation for MCOT. MCOT may be a reasonable alternative AF screening tool for patients with cryptogenic stroke if ILR is not available. PROSPERO registration number CRD42022297782.
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Affiliation(s)
- Haowen Jiang
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Shyn Yi Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jeremy King Wang
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jiaqi Li
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Tian Ming Tu
- Neurology, National Neuroscience Institute, Singapore
| | | | - Colin Yeo
- Cardiology, Changi General Hospital, Singapore
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11
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Rubiera M, Aires A, Antonenko K, Lémeret S, Nolte CH, Putaala J, Schnabel RB, Tuladhar AM, Werring DJ, Zeraatkar D, Paciaroni M. European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. Eur Stroke J 2022; 7:VI. [PMID: 36082257 PMCID: PMC9446336 DOI: 10.1177/23969873221099478] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to provide practical recommendations for the screening of subclinical atrial fibrillation (AF) in patients with ischaemic stroke or transient ischaemic attack (TIA) of undetermined origin. These guidelines are based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Five relevant Population, Intervention, Comparator, Outcome questions were defined by a multidisciplinary module working group (MWG). Longer duration of cardiac rhythm monitoring increases the detection of subclinical AF, but the optimal monitoring length is yet to be defined. We advise longer monitoring to increase the rate of anticoagulation, but whether longer monitoring improves clinical outcomes needs to be addressed. AF detection does not differ from in- or out-patient ECG-monitoring with similar monitoring duration, so we consider it reasonable to initiate in-hospital monitoring as soon as possible and continue with outpatient monitoring for more than 48h. Although insertable loop recorders (ILR) increase AF detection based on their longer monitoring duration, comparison with non-implantable ECG devices for similar monitoring time is lacking. We suggest the use of implantable devices, if feasible, for AF detection instead of non- implantable devices to increase the detection of subclinical AF. There is weak evidence of a useful role for blood, ECG, and brain imaging biomarkers for the identification of patients at high risk of AF. In patients with patent foramen ovale, we found insufficient evidence from RCT, but prolonged cardiac monitoring in patients >55 years is advisable for subclinical AF detection. To conclude, in adult patients with ischaemic stroke or TIA of undetermined origin, we recommend longer duration of cardiac rhythm monitoring of more than 48h and if feasible with IRL to increase the detection of subclinical AF.
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Affiliation(s)
- Marta Rubiera
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
| | - Ana Aires
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Kateryna Antonenko
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt- Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Renate B. Schnabel
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck Germany
| | - Anil M Tuladhar
- Department of Neurology, Donders Center for Medical Neurosciences, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Dena Zeraatkar
- Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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12
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A Review of the Wide Range of Indications and Uses of Implantable Loop Recorders: A Review of the Literature. HEARTS 2022. [DOI: 10.3390/hearts3020007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Implantable loop recorders (ILR) are devices that are implanted subcutaneously on the chest, which enables the continuous monitoring of arrhythmias for up to three years. These devices have an important role in helping to make a diagnosis and supporting decisions about the best patient management. There are currently three companies that produce ILRs. The Reveal DX and XT device is produced by Medtronic. The Confirm device is produced by Abbott. The Biomonitor III device is produced by Biotronik. The established indications for ILR include the management of transient loss of consciousness and the diagnosis of undocumented palpitations; however, they are also used for less established applications, including atrial fibrillation (AF) monitoring and risk stratification in patients with previous myocardial infarction or inherited cardiomyopathies. There is also diverse literature exploring the use of these devices in other populations, including patients with conditions such as congenital heart disease, amyloidosis, stroke, obstructive sleep apnea, renal transplant and patients who undergo procedures such as AF ablation and coronary artery bypass graft. In this review, we describe how the use of ILR has been applied in different settings, including patients with cardiac and non-cardiac conditions as well as post-cardiac procedures. We then discuss the potential issues related to using ILR in these other indications.
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13
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Rakhimova I, Semenova Y, Khaibullin T, Kuanysheva A, Kovalchuk V, Abdrakhmanov A. Cryptogenic Stroke and Embolic Stroke of Undetermined Source: Risk Factors and Approaches for Detection of Atrial Fibrillation. Curr Cardiol Rev 2022; 18:e211221199213. [PMID: 34939547 PMCID: PMC9893140 DOI: 10.2174/1573403x18666211221145714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/17/2021] [Accepted: 11/03/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stroke is a problem worldwide because of its high mortality and disability rates. Almost 90% of strokes are ischemic, and more than half of the deaths are caused by an ischemic stroke. Most risk factors for stroke are manageable so that it can be avoided with proper prevention. Despite the success in determining the causes of stroke in recent years, selectively, the "culprit" causing stroke remains unsolved. In such cases, a diagnosis of undetermined etiology (cryptogenic stroke) or embolic stroke of undetermined source (ESUS) is generated, resulting the prevention of a recurrent cerebrovascular occurrence impossible. Atrial fibrillation (AF) can be a cause of stroke by causing blood clots in the chambers of the heart. PURPOSE The aim was to determine the optimal method of heart rate monitoring in patients with ischemic stroke, as methods and approaches for detecting AF are very diverse, but there is still no single opinion, which would be universal. PROCEDURES In our review, we consider epidemiology, risk factors for the stroke of undetermined etiology, as well as analytical methods for detecting heart rhythm disturbances in this category of patients. FINDINGS Atrial fibrillation (AF) is detected by thorough monitoring of heart rate of patients with cryptogenic stroke and ESUS can be diagnosed in up to 46% of patients. . CONCLUSION After AF detection, consideration should be given to prescribing anticoagulants, instead of antiplatelet agents, for the secondary prevention of stroke.
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Affiliation(s)
- Idaliya Rakhimova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Yuliya Semenova
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Talgat Khaibullin
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Anargul Kuanysheva
- Department of Cardiology and Interventional Arrhythmology, Semey State Medical University, Semey, Kazakhstan
| | - Vitalii Kovalchuk
- Department of Semashko City Hospital, Saint Petersburg, Russian Federation
| | - Ayan Abdrakhmanov
- National Research Cardiac Surgery Center, Nur-Sultan 010000, Kazakhstan
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14
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Medic G, Kotsopoulos N, Connolly MP, Lavelle J, Norlock V, Wadhwa M, Mohr BA, Derkac WM. Mobile Cardiac Outpatient Telemetry Patch vs Implantable Loop Recorder in Cryptogenic Stroke Patients in the US - Cost-Minimization Model. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:445-458. [PMID: 34955658 PMCID: PMC8694406 DOI: 10.2147/mder.s337142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/06/2021] [Indexed: 01/15/2023] Open
Abstract
Purpose The aim of this study was to compare costs and outcomes of mobile cardiac outpatient telemetry (MCOT) patch followed by implantable loop recorder (ILR) compared to ILR alone in cryptogenic stroke patients from the US health-care payors’ perspective. Patients and Methods A quantitative decision tree cost-minimization simulation model was developed. Eligible patients were 18 years of age or older and were diagnosed with having a cryptogenic stroke, without previously documented atrial fibrillation (AF). All patients were assigned first to one then to the alternative monitoring strategies. Following AF detection, patients were initiated on oral anticoagulants (OAC). The model assessed direct costs for one year attributed to MCOT patch followed by ILR or ILR alone using a monitoring duration of 30 days post-cryptogenic stroke. Results In the base case modeling, the MCOT patch arm detected 4.6 more patients with AFs compared to the ILR alone arm in a cohort of 1000 patients (209 vs 45 patients with detected AFs, respectively). Using MCOT patch followed by ILR in half of the patients initially undiagnosed with AF leads to significant cost savings of US$4,083,214 compared to ILR alone in a cohort of 1000 patients. Cost per patient with detected AF was significantly lower in the MCOT patch arm $29,598 vs $228,507 in the ILR only arm. Conclusion An initial strategy of 30-day electrocardiogram (ECG) monitoring with MCOT patch in diagnosis of AF in cryptogenic stroke patients realizes significant cost-savings compared to proceeding directly to ILR only. Almost 8 times lower costs were achieved with improved detection rates and reduction of secondary stroke risk due to new anticoagulant use in subjects with MCOT patch detected AF. These results strengthen emerging recommendations for prolonged ECG monitoring in secondary stroke prevention.
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Affiliation(s)
- Goran Medic
- Chief Medical Office, Philips Healthcare, Eindhoven, Netherlands.,Department of Pharmacy, University of Groningen, Groningen, Netherlands
| | | | - Mark P Connolly
- Department of Pharmacy, University of Groningen, Groningen, Netherlands.,Global Market Access Solutions LLC, Charlotte, NC, USA
| | | | | | - Manish Wadhwa
- BioTelemetry, Inc., A Philips Company, Malvern, PA, USA
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15
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Aggarwal G, Aggarwal S, Alla V, Narasimhan B, Ryu K, Jeffery C, Lakkireddy D. Subcutaneouscardiac Rhythm Monitors: A Comprehensive Review. J Atr Fibrillation 2021; 13:2387. [PMID: 34950332 DOI: 10.4022/jafib.2387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/15/2020] [Accepted: 01/08/2021] [Indexed: 01/14/2023]
Abstract
Subcutaneous loop recorders (SCRMs) are subcutaneous electronic devices which have revolutionized the field of arrhythmia detection. They have become increasingly appealing due to advances such as miniaturization of device, longer battery life, bluetooth capabilities and relatively simple implantation technique without the need for complex surgical suites. They can be implanted in the office, patient bedside without the need to go to the operating room. One of the most common indications for their implantation is detection of atrial fibrillation (AF) after a cryptogenic stroke. They have also been utilized for assessing the success of rhythm control strategies such post pulmonary venous isolation. More recently studies have assessed the utility of SCRMs for detecting silent AF in at risk populations such as patients with sleep apnea or those on hemodialysis. In this paper, we review the evolution of SCRMs, the clinical studies assessing their value for different indications, their role incurrent clinical practice and future avenues in the era of smart wearable devices like apple watch etc.
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Affiliation(s)
- Gaurav Aggarwal
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ
| | | | - Venkata Alla
- Division of Cardiology, Department of Medicine, Creighton University School of Medicine, Omaha, NE
| | - Bharat Narasimhan
- Department of Medicine, St Luke's Roosevelt Hospital at Icahn School of Medicine, New York, NY
| | | | - Courtney Jeffery
- The Kansas City Heart Rhythm Institution and Research Foundation, Overland Park, KS
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16
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Sagris D, Georgiopoulos G, Pateras K, Perlepe K, Korompoki E, Milionis H, Tsiachris D, Chan C, Lip GYH, Ntaios G. Atrial High-Rate Episode Duration Thresholds and Thromboembolic Risk: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e022487. [PMID: 34755543 PMCID: PMC8751956 DOI: 10.1161/jaha.121.022487] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Available evidence supports an association between atrial high‐rate episode (AHRE) burden and thromboembolic risk, but the necessary extent and duration of AHREs to increase the thromboembolic risk remain to be defined. The aim of this systematic review and meta‐analysis was to identify the thromboembolic risk associated with various AHRE thresholds. Methods and Results We searched PubMed and Scopus until January 9, 2020, for literature reporting AHRE duration and thromboembolic risk in patients with implantable electronic devices. The outcome assessed was stroke or systemic embolism. Risk estimates were reported as hazard ratio (HR) or relative risk alongside 95% CIs. We used the Paule‐Mandel estimator, and heterogeneity was calculated with I2 index. Among 27 studies including 61 919 patients, 23 studies reported rates according to the duration of the longest AHRE and 4 studies reported rates according to the cumulative day‐level AHRE duration. In patients with cardiac implantable devices, AHREs lasting ≥30 seconds significantly increased the risk of stroke or systemic embolism (HR, 4.41; 95% CI, 2.32–8.39; I2, 5.5%), which remained consistent for the thresholds of 5 minutes and 6 and 24 hours. Patients with previous stroke or transient ischemic attack and AHREs lasting ≥2 minutes had a marginally increased risk of recurrent stroke or transient ischemic attack. The risk of stroke or systemic embolism was higher in patients with cumulative AHRE ≥24 hours compared with those of shorter duration or no AHRE (HR, 1.25; 95% CI, 1.04–1.52; I2, 0%). Conclusions This systematic review and meta‐analysis suggests that single AHRE episodes ≥30 seconds and cumulative AHRE duration ≥24 hours are associated with increased risk of stroke or systemic embolism.
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Affiliation(s)
- Dimitrios Sagris
- Department of Internal Medicine School of Health Sciences Faculty of Medicine University of Thessaly Larissa Greece
| | - Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences King's College London United Kingdom
| | - Konstantinos Pateras
- Department of Biostatistics and Research Support Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht the Netherlands
| | - Kalliopi Perlepe
- Department of Internal Medicine School of Health Sciences Faculty of Medicine University of Thessaly Larissa Greece
| | - Eleni Korompoki
- Department of Clinical Therapeutics National and Kapodistrian University of Athens Athens Greece
| | - Haralampos Milionis
- Department of Internal Medicine University Hospital of Ioannina Ioannina Greece
| | - Dimitrios Tsiachris
- Athens Heart Center Athens Medical Center Athens Greece.,1st Cardiology Department Athens Medical School National and Kapodistrian University of Athens Athens Greece
| | - Cheuk Chan
- School of Biomedical Engineering and Imaging Sciences King's College London United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart and Chest Hospital Liverpool United Kingdom.,Aalborg Thrombosis Research Unit Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - George Ntaios
- Department of Internal Medicine School of Health Sciences Faculty of Medicine University of Thessaly Larissa Greece
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17
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Cameron A, Cheng HK, Lee RP, Doherty D, Hall M, Khashayar P, Lip GYH, Quinn T, Abdul-Rahim A, Dawson J. Biomarkers for Atrial Fibrillation Detection After Stroke: Systematic Review and Meta-analysis. Neurology 2021; 97:e1775-e1789. [PMID: 34504030 DOI: 10.1212/wnl.0000000000012769] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/18/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVE To identify clinical, ECG, and blood-based biomarkers associated with atrial fibrillation (AF) detection after ischaemic stroke or TIA that could help inform patient selection for cardiac monitoring. METHODS We performed a systematic review and meta-analysis and searched electronic databases for cohort studies from January 15, 2000, to January 15, 2020. The outcome was AF ≥30 seconds within 1 year after ischemic stroke/TIA. We used random effects models to create summary estimates of risk. Risk of bias was assessed using the Quality in Prognostic Studies tool. RESULTS We identified 8,503 studies, selected 34 studies, and assessed 69 variables (42 clinical, 20 ECG, and 7 blood-based biomarkers). The studies included 11,569 participants and AF was detected in 1,478 (12.8%). Overall, risk of bias was moderate. Variables associated with increased likelihood of AF detection are older age (odds ratio [OR] 3.26, 95% confidence interval [CI] 2.35-4.54), female sex (OR 1.47, 95% CI 1.23-1.77), a history of heart failure (OR 2.56, 95% CI 1.87-3.49), hypertension (OR 1.42, 95% CI 1.15-1.75) or ischemic heart disease (OR 1.80, 95% CI 1.34-2.42), higher modified Rankin Scale (OR 6.13, 95% CI 2.93-12.84) or National Institutes of Health Stroke Scale score (OR 2.50, 95% CI 1.64-3.81), no significant carotid/intracranial artery stenosis (OR 3.23, 95% CI 1.14-9.11), no tobacco use (OR 1.93, 95% CI 1.48-2.51), statin therapy (OR 2.07, 95% CI 1.14-3.73), stroke as index diagnosis (OR 1.59, 95% CI 1.17-2.18), systolic blood pressure (OR 1.61, 95% CI 1.16-2.22), IV thrombolysis treatment (OR 2.40, 95% CI 1.83-3.16), atrioventricular block (OR 2.12, 95% CI 1.08-4.17), left ventricular hypertrophy (OR 2.21, 95% CI 1.03-4.74), premature atrial contraction (OR 3.90, 95% CI 1.74-8.74), maximum P-wave duration (OR 3.19, 95% CI 1.40-7.25), PR interval (OR 2.32, 95% CI 1.11-4.83), P-wave dispersion (OR 7.79, 95% CI 4.16-14.61), P-wave index (OR 3.44, 95% CI 1.87-6.32), QTc interval (OR 3.68, 95% CI 1.63-8.28), brain natriuretic peptide (OR 13.73, 95% CI 3.31-57.07), and high-density lipoprotein cholesterol (OR 1.49, 95% CI 1.17-1.88) concentrations. Variables associated with reduced likelihood are minimum P-wave duration (OR 0.53, 95% CI 0.29-0.98), low-density lipoprotein cholesterol (OR 0.73, 95% CI 0.57-0.93), and triglyceride (OR 0.51, 95% CI 0.41-0.64) concentrations. DISCUSSION We identified multimodal biomarkers that could help guide patient selection for cardiac monitoring after ischaemic stroke/TIA. Their prognostic utility should be prospectively assessed with AF detection and recurrent stroke as outcomes.
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Affiliation(s)
- Alan Cameron
- From the Institute of Cardiovascular and Medical Sciences (A.C., H.K.C., R.-P.L., D.D., M.H., P.K., T.Q., J.D.) and Institute of Neuroscience and Psychology (A.A.-R.), University of Glasgow, UK; Faculty of Medicine (H.K.C.), University of Hong Kong, Pokfulam; and Liverpool Centre for Cardiovascular Science (G.L.), University of Liverpool, UK.
| | - Huen Ki Cheng
- From the Institute of Cardiovascular and Medical Sciences (A.C., H.K.C., R.-P.L., D.D., M.H., P.K., T.Q., J.D.) and Institute of Neuroscience and Psychology (A.A.-R.), University of Glasgow, UK; Faculty of Medicine (H.K.C.), University of Hong Kong, Pokfulam; and Liverpool Centre for Cardiovascular Science (G.L.), University of Liverpool, UK
| | - Ren-Ping Lee
- From the Institute of Cardiovascular and Medical Sciences (A.C., H.K.C., R.-P.L., D.D., M.H., P.K., T.Q., J.D.) and Institute of Neuroscience and Psychology (A.A.-R.), University of Glasgow, UK; Faculty of Medicine (H.K.C.), University of Hong Kong, Pokfulam; and Liverpool Centre for Cardiovascular Science (G.L.), University of Liverpool, UK
| | - Daniel Doherty
- From the Institute of Cardiovascular and Medical Sciences (A.C., H.K.C., R.-P.L., D.D., M.H., P.K., T.Q., J.D.) and Institute of Neuroscience and Psychology (A.A.-R.), University of Glasgow, UK; Faculty of Medicine (H.K.C.), University of Hong Kong, Pokfulam; and Liverpool Centre for Cardiovascular Science (G.L.), University of Liverpool, UK
| | - Mark Hall
- From the Institute of Cardiovascular and Medical Sciences (A.C., H.K.C., R.-P.L., D.D., M.H., P.K., T.Q., J.D.) and Institute of Neuroscience and Psychology (A.A.-R.), University of Glasgow, UK; Faculty of Medicine (H.K.C.), University of Hong Kong, Pokfulam; and Liverpool Centre for Cardiovascular Science (G.L.), University of Liverpool, UK
| | - Pouria Khashayar
- From the Institute of Cardiovascular and Medical Sciences (A.C., H.K.C., R.-P.L., D.D., M.H., P.K., T.Q., J.D.) and Institute of Neuroscience and Psychology (A.A.-R.), University of Glasgow, UK; Faculty of Medicine (H.K.C.), University of Hong Kong, Pokfulam; and Liverpool Centre for Cardiovascular Science (G.L.), University of Liverpool, UK
| | - Gregory Y H Lip
- From the Institute of Cardiovascular and Medical Sciences (A.C., H.K.C., R.-P.L., D.D., M.H., P.K., T.Q., J.D.) and Institute of Neuroscience and Psychology (A.A.-R.), University of Glasgow, UK; Faculty of Medicine (H.K.C.), University of Hong Kong, Pokfulam; and Liverpool Centre for Cardiovascular Science (G.L.), University of Liverpool, UK
| | - Terence Quinn
- From the Institute of Cardiovascular and Medical Sciences (A.C., H.K.C., R.-P.L., D.D., M.H., P.K., T.Q., J.D.) and Institute of Neuroscience and Psychology (A.A.-R.), University of Glasgow, UK; Faculty of Medicine (H.K.C.), University of Hong Kong, Pokfulam; and Liverpool Centre for Cardiovascular Science (G.L.), University of Liverpool, UK
| | - Azmil Abdul-Rahim
- From the Institute of Cardiovascular and Medical Sciences (A.C., H.K.C., R.-P.L., D.D., M.H., P.K., T.Q., J.D.) and Institute of Neuroscience and Psychology (A.A.-R.), University of Glasgow, UK; Faculty of Medicine (H.K.C.), University of Hong Kong, Pokfulam; and Liverpool Centre for Cardiovascular Science (G.L.), University of Liverpool, UK
| | - Jesse Dawson
- From the Institute of Cardiovascular and Medical Sciences (A.C., H.K.C., R.-P.L., D.D., M.H., P.K., T.Q., J.D.) and Institute of Neuroscience and Psychology (A.A.-R.), University of Glasgow, UK; Faculty of Medicine (H.K.C.), University of Hong Kong, Pokfulam; and Liverpool Centre for Cardiovascular Science (G.L.), University of Liverpool, UK
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18
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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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19
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Ble M, Benito B, Cuadrado-Godia E, Pérez-Fernández S, Gómez M, Mas-Stachurska A, Tizón-Marcos H, Molina L, Martí-Almor J, Cladellas M. Left Atrium Assessment by Speckle Tracking Echocardiography in Cryptogenic Stroke: Seeking Silent Atrial Fibrillation. J Clin Med 2021; 10:jcm10163501. [PMID: 34441797 PMCID: PMC8397042 DOI: 10.3390/jcm10163501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/31/2021] [Accepted: 08/04/2021] [Indexed: 01/01/2023] Open
Abstract
Silent atrial fibrillation (AF) may be the cause of some cryptogenic strokes (CrS). The aim of the study was to analyse atrial size and function by speckle tracking echocardiography in CrS patients to detect atrial disease. Patients admitted to the hospital due to CrS were included prospectively. Echocardiogram analysis included left atrial ejection fraction (LAEF) and atrial strain. Insertable cardiac monitor was implanted, and AF was defined as an episode of ≥1 min in the first year after stroke. Left atrial enlargement was defined as indexed volume > 34 mL/m2. Seventy-five consecutive patients were included, aged 76 ± 9 years (arterial hypertension 75%). AF was diagnosed in 49% of cases. The AF group had higher atrial volume and worse atrial function: peak atrial longitudinal strain (PALs) 19.6 ± 5.7% vs. 29.5 ± 7.2%, peak atrial contraction strain (PACs) 8.9 ± 3.9% vs. 16.5 ± 6%, LAEF 46.8 ± 11.5% vs. 60.6 ± 5.2%; p < 0.001. AF was diagnosed in 20 of 53 patients with non-enlarged atrium, and in 18 of them, atrial dysfunction was present. The multivariate logistic regression analysis demonstrated an independent association between detection of AF and atrial volume, LAEF, and strain. Cut-off values were obtained: LAEF < 55%, PALs < 21.4%, and PACs < 12.9%. In conclusion, speckle tracking echocardiography in CrS patients improves silent atrial disease diagnosis, with or without atrial enlargement.
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Affiliation(s)
- Mireia Ble
- Medicine Department, Universidad Autónoma de Barcelona, 08035 Barcelona, Spain;
- Cardiology Department, Hospital del Mar, Parc de Salut Mar, 08003 Barcelona, Spain; (A.M.-S.); (H.T.-M.); (L.M.); (J.M.-A.)
- Correspondence: ; Tel.: +34-932-483-018
| | - Begoña Benito
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain; (B.B.); (E.C.-G.); (S.P.-F.)
- Cardiology Department, Hospital Vall d’Hebron, 08035 Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain; (B.B.); (E.C.-G.); (S.P.-F.)
- Neurology Department, Hospital del Mar, Parc de Salut Mar, 08003 Barcelona, Spain
| | - Sílvia Pérez-Fernández
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain; (B.B.); (E.C.-G.); (S.P.-F.)
- CIBER of Cardiovascular Diseases (CIBERCV), 08003 Barcelona, Spain
| | - Miquel Gómez
- Cardiology Department, Hospital de Barcelona, 08034 Barcelona, Spain;
| | - Aleksandra Mas-Stachurska
- Cardiology Department, Hospital del Mar, Parc de Salut Mar, 08003 Barcelona, Spain; (A.M.-S.); (H.T.-M.); (L.M.); (J.M.-A.)
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain; (B.B.); (E.C.-G.); (S.P.-F.)
| | - Helena Tizón-Marcos
- Cardiology Department, Hospital del Mar, Parc de Salut Mar, 08003 Barcelona, Spain; (A.M.-S.); (H.T.-M.); (L.M.); (J.M.-A.)
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain; (B.B.); (E.C.-G.); (S.P.-F.)
| | - Lluis Molina
- Cardiology Department, Hospital del Mar, Parc de Salut Mar, 08003 Barcelona, Spain; (A.M.-S.); (H.T.-M.); (L.M.); (J.M.-A.)
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain; (B.B.); (E.C.-G.); (S.P.-F.)
- Cardiology Department, Hospital de Barcelona, 08034 Barcelona, Spain;
| | - Julio Martí-Almor
- Cardiology Department, Hospital del Mar, Parc de Salut Mar, 08003 Barcelona, Spain; (A.M.-S.); (H.T.-M.); (L.M.); (J.M.-A.)
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain; (B.B.); (E.C.-G.); (S.P.-F.)
| | - Mercè Cladellas
- Medicine Department, Universidad Autónoma de Barcelona, 08035 Barcelona, Spain;
- Cardiology Department, Hospital del Mar, Parc de Salut Mar, 08003 Barcelona, Spain; (A.M.-S.); (H.T.-M.); (L.M.); (J.M.-A.)
- Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain; (B.B.); (E.C.-G.); (S.P.-F.)
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20
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Dickson EL, Ding EY, Saczynski JS, Han D, Moonis M, Fitzgibbons TP, Barton B, Chon K, McManus DD. Smartwatch monitoring for atrial fibrillation after stroke—The Pulsewatch Study: Protocol for a multiphase randomized controlled trial. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2021; 2:231-241. [PMID: 35265913 PMCID: PMC8890084 DOI: 10.1016/j.cvdhj.2021.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Atrial fibrillation (AF) is a common heart rhythm disorder that elevates stroke risk. Stroke survivors undergo routine heart rhythm monitoring for AF. Smartwatches are capable of AF detection and potentially can replace traditional cardiac monitoring in stroke patients. Objective The goal of Pulsewatch is to assess the accuracy, usability, and adherence of a smartwatch-based AF detection system in stroke patients. Methods The study will consist of two parts. Part I will have 6 focus groups with stroke patients, caretakers, and physicians, and a Hack-a-thon, to inform development of the Pulsewatch system. Part II is a randomized clinical trial with 2 phases designed to assess the accuracy and usability in the first phase (14 days) and adherence in the second phase (30 days). Participants will be randomized in a 3:1 ratio (intervention to control) for the first phase, and both arms will receive gold-standard electrocardiographic (ECG) monitoring. The intervention group additionally will receive a smartphone/smartwatch dyad with the Pulsewatch applications. Upon completion of 14 days, participants will be re-randomized in a 1:1 ratio. The intervention group will receive the Pulsewatch system and a handheld ECG device, while the control group will be passively monitored. Participants will complete questionnaires at enrollment and at 14- and 44-day follow-up visits to assess various psychosocial measures and health behaviors. Results Part I was completed in August 2019. Enrollment for Part II began September 2019, with expected completion by the end of 2021. Conclusion Pulsewatch aims to demonstrate that a smartwatch can be accurate for real-time AF detection, and that older stroke patients will find the system usable and will adhere to monitoring.
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21
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Albers GW, Bernstein R, Brachmann J, Camm AJ, Fromm P, Goto S, Granger CB, Hohnloser SH, Hylek E, Krieger D, Passman R, Pines JM, Kowey P. Reexamination of the Embolic Stroke of Undetermined Source Concept. Stroke 2021; 52:2715-2722. [PMID: 34192898 DOI: 10.1161/strokeaha.121.035208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Occult atrial fibrillation (AF) is a leading cause of stroke of unclear cause. The optimal approach to secondary stroke prevention for these patients remains elusive. The term embolic stroke of undetermined source (ESUS) was coined to describe ischemic strokes in which the radiographic features demonstrate territorial infarcts resembling those seen in patients with confirmed sources of embolism but without a clear source of embolism detected. It was assumed that patients with ESUS had a high rate of occult AF and would benefit from treatment with direct oral anticoagulants, which are at least as effective as vitamin K antagonists for secondary stroke prevention in patients with AF, but with a much lower risk of intracerebral hemorrhage. Two recent large randomized trials failed to show superiority of direct oral anticoagulants over aspirin in ESUS patients. These findings prompt a reexamination of the ESUS concept, with the goal of improving specificity for detecting patients with a cardioembolic cause. Based on the negative trial results, there is renewed interest in the role of long-term cardiac monitoring for AF in patients who fit the current ESUS definition, as well as the clinical implication of detecting AF. Ongoing trials are exploring these questions. Current ESUS definitions do not accurately detect the patients who should be prescribed direct oral anticoagulants, potentially because occult AF is less common than expected in these patients and/or anticoagulants may be less beneficial in patients with ESUS but no AF than they are for patients with stroke with established AF. More specific criteria to identify patients who may be at higher risk for occult AF and reduce their risk of subsequent stroke have been developed and are being tested in ongoing clinical trials.
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Affiliation(s)
- Gregory W Albers
- Department of Neurology and the Stanford Stroke Center, Stanford Medical Center, CA (G.W.A.)
| | | | - Johannes Brachmann
- REGIOMED Centrum for Cardiology and Angiology, Kliniken Coburg, II Med Klinik, Germany (J.B.)
| | - A John Camm
- St. George's University of London, United Kingdom (A.J.C.)
| | - Peter Fromm
- Mount Sinai South Nassau, Oceanside, NY (P.F.)
| | - Shinya Goto
- Tokai University School of Medicine, Tokyo, Japan (S.G.)
| | | | | | | | - Derk Krieger
- Mediclinic City Hospital, Mohamed Bin Rashid University, Dubai Health Care City, Dubai, United Arab Emirates (D.K.)
| | - Rod Passman
- Northwestern Memorial Hospital, Chicago, IL (R.P.)
| | | | - Peter Kowey
- Lankenau Hospital and Medical Research Center, Wynnewood, PA (P.K.)
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22
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Lu Y, Diao SS, Huang SJ, Zhao JJ, Ye MF, Yao FR, Kong Y, Xu Z. Insertable cardiac monitors for detection of atrial fibrillation after cryptogenic stroke: a meta-analysis. Neurol Sci 2021; 42:4139-4148. [PMID: 33528671 DOI: 10.1007/s10072-021-05104-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/29/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND In recent years, the implantable cardiac monitors (ICM) have enhanced the recognition ability of atrial fibrillation (AF), which makes ICM have a new application in AF detection. We conducted a meta-analysis to determine the total incidence of newly found AF detected by ICM after cryptogenic stroke and to evaluate the factors related to the detection of AF. METHODS A literature search was conducted in the PubMed, EMBASE, Web of Science, and Cochrane library databases until March 1, 2020. Studies that reported the detection rate of AF using ICM in cryptogenic stroke patients with negative initial AF screening were analyzed. RESULTS A total of 23 studies were included. The overall proportion of AF detected by ICM in cryptogenic stroke patients was 25% (95% confidence interval [CI], 22-29%). The rate of AF detected by ICM was independently related to both cardiac monitoring time (coefficient = 0.0003; 95% CI, 0.0001-0.0005; P = 0.0001) and CHA2DS2-VASc score (coefficient = 0.0834; 95% CI, 0.0339-0.1329; P = 0.001). In subgroup analysis, we found a significant difference in the detection rate of AF for monitoring duration (< 6 months: 9.6% [95% CI, 4.4-16.4%]; ≥ 6 and ≤ 12 months: 19.3% [95% CI, 15.9-23.0%]; > 12 and ≤ 24 months: 23.6% [95% CI, 19.9-27.5%]; > 24 months and ≤ 36 months: 36.5% [95% CI, 24.2-49.9%]; P < 0.001), and continent (Europe: 26.5% [95% CI, 22.2-31.0%]; North America: 16.0% [95% CI, 10.3-22.6%]; Asia: 17.4% [95% CI, 12.4-23.0%]; P = 0.005). CONCLUSIONS The longer the time of ICM monitoring after cryptogenic stroke, the higher the detection rate of AF. Further research is still needed to determine the optimal duration of long-term cardiac monitoring.
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Affiliation(s)
- Yue Lu
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Shan-Shan Diao
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Shuang-Jiao Huang
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Jie-Ji Zhao
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Meng-Fan Ye
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Fei-Rong Yao
- Department of Radiology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China
| | - Yan Kong
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China.
| | - Zhuan Xu
- Department of Neurology, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu, China.
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23
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Jawad-Ul-Qamar M, Chua W, Purmah Y, Nawaz M, Varma C, Davis R, Maher A, Fabritz L, Kirchhof P. Detection of unknown atrial fibrillation by prolonged ECG monitoring in an all-comer patient cohort and association with clinical and Holter variables. Open Heart 2020; 7:openhrt-2019-001151. [PMID: 32371464 PMCID: PMC7223355 DOI: 10.1136/openhrt-2019-001151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/12/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Prolonged ECG monitoring is clinically useful to detect unknown atrial fibrillation (AF) in stroke survivors. The diagnostic yield of prolonged ECG monitoring in other patient populations is less well characterised. We therefore studied the diagnostic yield of prolonged Holter ECG monitoring for AF in an unselected patient cohort referred from primary care or seen in a teaching hospital. METHODS We analysed consecutive 7-day ECG recordings in unselected patients referred from different medical specialities and assessed AF detection rates by indication, age and comorbidities. RESULTS Seven-day Holter ECGs (median monitoring 127.5 hours, IQR 116 to 152) were recorded in 476 patients (mean age 54.6 (SD 17.0) years, 55.9% female) without previously known AF, requested to evaluate palpitations (n=241), syncope (n=99), stroke or transient ischaemic attack (n=75), dizziness (n=29) or episodic chest pain (n=32). AF was newly detected in 42/476 (8.8%) patients. Oral anticoagulation was initiated in 40/42 (95.2%) patients with newly detected AF. Multivariate logistic regression, adjusted for age, sex and monitoring duration found four clinical parameters to be associated with newly detected AF: hypertension OR=2.54, (1.08 to 8.61) (adjusted OR (95% CI)), p=0.034; previous stroke or TIA OR=4.14 (1.81 to 13.01), p=0.001; left-sided valvular heart disease OR=5.07 (2.48 to 18.70), p<0.001 and palpitations OR=2.86, (1.33 to 10.44), p=0.015. CONCLUSIONS Open multispeciality access to prolonged ECG monitoring, for example, as part of integrated, cross-sector AF care, can accelerate diagnosis of AF and increase adequate use of oral anticoagulation, especially in older and symptomatic patients with comorbidities.
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Affiliation(s)
- Muhammad Jawad-Ul-Qamar
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Yanish Purmah
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Mohammad Nawaz
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Chetan Varma
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Russell Davis
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Abdul Maher
- Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK .,Department of Cardiology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK.,University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
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24
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Chew DS, Rennert-May E, Quinn FR, Buck B, Hill MD, Spackman E, Manns BJ, Exner DV. Economic evaluation of extended electrocardiogram monitoring for atrial fibrillation in patients with cryptogenic stroke. Int J Stroke 2020; 16:809-817. [PMID: 33232196 DOI: 10.1177/1747493020974561] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Timely identification of occult atrial fibrillation following cryptogenic stroke facilitates consideration of oral anticoagulation therapy. Extended electrocardiography monitoring beyond 24 to 48 h Holter monitoring improves atrial fibrillation detection rates, yet uncertainty remains due to upfront costs and the projected long-term benefit. We sought to determine the cost-effectiveness of three electrocardiography monitoring strategies in detecting atrial fibrillation after cryptogenic stroke. METHODS A decision-analytic Markov model was used to project the costs and outcomes of three different electrocardiography monitoring strategies (i.e. 30-day electrocardiography monitoring, three-year implantable loop recorder monitoring, and conventional Holter monitoring) in acute stroke survivors without previously documented atrial fibrillation. RESULTS The lifetime discounted costs and quality-adjusted life years were $206,385 and 7.77 quality-adjusted life years for conventional monitoring, $207,080 and 7.79 quality-adjusted life years for 30-day extended electrocardiography monitoring, and $210,728 and 7.88 quality-adjusted life years for the implantable loop recorder strategy. Additional quality-adjusted life years could be attained at a more favorable incremental cost per quality-adjusted life year with the implantable loop recorder strategy, compared with the 30-day electrocardiography monitoring strategy, thereby eliminating the 30-day strategy by extended dominance. The implantable loop recorder strategy was associated with an incremental cost per quality-adjusted life year gained of $40,796 compared with conventional monitoring. One-way sensitivity analyses indicated that the model was most sensitive to the rate of recurrent ischemic stroke. CONCLUSIONS An implantable loop recorder strategy for detection of occult atrial fibrillation in patients with cryptogenic stroke is more economically attractive than 30-day electrocardiography monitoring compared to conventional monitoring and is associated with a cost per quality-adjusted life year gained in the range of other publicly funded therapies. The value proposition is improved when considering patients at the highest risk of recurrent ischemic stroke. However, the implantable loop recorder strategy is associated with increased health care costs, and the opportunity cost of wide scale implementation must be considered.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.,Department of Cardiac Sciences, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Elissa Rennert-May
- Department of Community Health Sciences, University of Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Alberta, Canada
| | - F Russell Quinn
- Department of Cardiac Sciences, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Eldon Spackman
- Department of Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Braden J Manns
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Derek V Exner
- Department of Cardiac Sciences, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
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25
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Smith A, Perdue M, Vojnika J, Frisch DR, Pavri BB. The diagnostic yield of implantable loop recorders stratified by indication: "real-world" use in a large academic hospital. J Interv Card Electrophysiol 2020; 61:303-311. [PMID: 32621215 DOI: 10.1007/s10840-020-00815-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/29/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To report on the clinical utility of implantable loop recorders (ILRs) in a large academic hospital setting over a 4-year period. METHODS Retrospective study (2013-2016) of patients receiving ILRs for any indication including syncope, cryptogenic stroke (CrS), atrial fibrillation (AF) burden, palpitations, ventricular arrhythmias (VA), and other. Remote checks, symptomatic transmissions, and in-person checks were reviewed. Time to diagnosis was documented. RESULTS A total of 263 patients (54% male, mean age 63 ± 15 years, mean follow-up 601 (range 9-1714) days) received ILRs for 324 indications; multiple indications were noted in 53/263 (20.2%) patients. ILR indications were 126 (39%) syncope, 81 (25%) CrS, 46 (14%) AF, 37 (11%) palpitations, 10 (3%) VA, and 24 (7%) other. Diagnostic yield for each indication was compared to the overall yield for all other indications. Three indications showed a significantly higher yield: AF (65% vs. 22%, p < 0.002), palpitations (60% vs. 24%, p < 0.001), and VA (70% vs. 28%, p < 0.004). For all other indications, there were no significant differences. Syncope had nearly half the diagnostic yield of previously published trials (28% vs. 43-56%). We observed a fourfold increase in ILR implant rate over the study duration. CONCLUSIONS In a "real-world" academic hospital setting, the diagnostic rate of ILRs was highest for AF, palpitations, and VA; however, these high yield indications comprised only 29% of all indications. The diagnostic yield for the commonest indication (syncope) was approximately half that reported in the previously published trials. With increasing implantation rates, additional studies are required to refine guideline-based indications for ILR implantation to improve diagnostic yield.
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Affiliation(s)
- Alexander Smith
- Department of Medicine, Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA, USA
| | - Makenzie Perdue
- Department of Medicine, Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA, USA
| | - Jetmir Vojnika
- Department of Medicine, Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA, USA
| | - Daniel R Frisch
- Department of Medicine, Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA, USA
| | - Behzad B Pavri
- Department of Medicine, Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA, USA.
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26
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Öner A, Lips T, Walter U, Storch A, Ince H, Caglayan E, Yücel S, Ortak J, Schmidt C. Detection of arrhythmia using an implantable cardiac monitor following a cryptogenic stroke: a single-center observational study. Eur J Med Res 2020; 25:25. [PMID: 32600384 PMCID: PMC7325047 DOI: 10.1186/s40001-020-00424-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 06/22/2020] [Indexed: 11/24/2022] Open
Abstract
Background Detection of atrial fibrillation (AF) after cryptogenic stroke (CS) has therapeutic implications, but the most effective type and optimal duration of monitoring have still to be defined. This study that involved patients with CS or transient ischemic attack (TIA), all of whom carried an implantable cardiac monitor (ICM), sought to assess the incidence of AF and other arrhythmia detected using tele-monitoring or interval-based follow-up by an internal cardiologist at the university medical center of Rostock (UMR) or an external cardiologist. Methods The ICM implantation was performed during the inpatient stay in the neurology department, with inclusion and exclusion criteria jointly determined by the neurology and cardiology departments. Cardiologists programmed individual threshold values during ICM implantation, which were designed to instantly trigger an episode being recording and an alarm message being sent out. Outpatient care consisted of tele-monitoring of implants or interval-based follow-up care. Results The indication for ICM implantation was made for 102 patients, 88 of whom underwent ICM implantation, with full documentation available for these 88 study patients. Within a median observation period of 21.5 months, AF occurred in 19 patients, with a median observation time to the event of 7 months. In all cases, AF detection was followed by immediate medical intervention. Comparing patients with and without AF revealed that the median age of the AF group exceeded by 10 years that of the other patients. Stroke recurrence was recorded in five patients, with a median observation time to the event of 9 months. Comparing patients with and without stroke recurrence revealed that the median age in the stroke recurrence group tended to be higher by 14 years. No statistically significant between-group differences were found with regard to integration into tele-monitoring, nor were there any differences identified between outpatient care at the UMR or in the outpatient sector. Conclusions This study confirmed the feasibility of using an interdisciplinary and intersectoral therapeutic approach for monitoring CS patients with implanted ICMs. Further randomized studies are warranted to confirm these encouraging data. An open discussion concerning optimal care forms and opportunities for introducing digitizing care pathways appears warranted.
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Affiliation(s)
- Alper Öner
- Department of Cardiology, Heart Center Rostock, University Hospital Rostock, Rostock, Germany. .,Medizinische Klinik I im Zentrum für Innere Medizin (ZIM), Ernst-Heydemann-Str. 6, 18057, Rostock, Germany.
| | - Thomas Lips
- Department of Cardiology, Heart Center Rostock, University Hospital Rostock, Rostock, Germany
| | - Uwe Walter
- Department of Neurology, University Hospital of Rostock, Rostock, Germany
| | - Alexander Storch
- Department of Neurology, University Hospital of Rostock, Rostock, Germany
| | - Hüseyin Ince
- Department of Cardiology, Heart Center Rostock, University Hospital Rostock, Rostock, Germany
| | - Evren Caglayan
- Department of Cardiology, Heart Center Rostock, University Hospital Rostock, Rostock, Germany
| | - Seyrani Yücel
- Department of Cardiology, Heart Center Rostock, University Hospital Rostock, Rostock, Germany
| | - Jasmin Ortak
- Department of Cardiology, Heart Center Rostock, University Hospital Rostock, Rostock, Germany
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27
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Tsai LK, Lee IH, Chen YL, Chao TF, Chen YW, Po HL, Lien LM, Chu PH, Huang WC, Lin TH, Lin MT, Jeng JS, Hwang JJ. Diagnosis and Treatment for embolic stroke of undetermined source: Consensus statement from the Taiwan stroke society and Taiwan society of cardiology. J Formos Med Assoc 2020; 120:93-106. [PMID: 32534996 DOI: 10.1016/j.jfma.2020.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/22/2020] [Accepted: 05/18/2020] [Indexed: 01/10/2023] Open
Abstract
Cryptogenic stroke comprises about one-quarter of ischemic strokes with high recurrence rate; however, studies specifically investigating the features and treatment of this stroke subtype are rare. The concept of 'embolic stroke of undetermined source' (ESUS) may facilitate the development of a standardized approach to diagnose cryptogenic stroke and improve clinical trials. Since recent large randomized control trials failed to demonstrate a reduction in stroke recurrence with anticoagulants, anti-platelet agents remain the first-line treatment for ESUS patients. Nevertheless, patients with high risk of stroke recurrence (e.g., those with repeated embolic infarcts despite aspirin treatment) require a more extensive survey of stroke etiology, including cardiac imaging and prolonged cardiac rhythm monitoring. Anticoagulant treatments may still benefit some subgroups of high-risk ESUS patients, such as those with multiple infarcts at different arterial territories without aortic atheroma, the elderly, or patients with high CHA2D2-VASc or HOVAC scores, atrial cardiopathy or patent foramen ovale. Several important ESUS clinical trials are ongoing, and the results are anticipated. With rapid progress in our understanding of ESUS pathophysiology, new subcategorizations of ESUS and assignment of optimal treatments for each ESUS subgroup are expected in the near future.
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Affiliation(s)
- Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan
| | - Helen L Po
- Stroke Center and Department of Neurology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ming-Tai Lin
- Division of Pediatric Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Juey-Jen Hwang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Pecha S, Wilke I, Yildirim Y, Reichenspurner H, Aydin MA. Implantable loop recorder monitoring in patients with cryptogenic stroke - Detection and treatment of different clinically relevant arrhythmias. J Electrocardiol 2020; 60:102-106. [PMID: 32339814 DOI: 10.1016/j.jelectrocard.2020.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/26/2020] [Accepted: 04/11/2020] [Indexed: 01/18/2023]
Abstract
AIMS Implantable loop recorders (ILR) are recommended to detect atrial fibrillation (AF) in cases of cryptogenic stroke. However, real life data besides controlled trials are rare. Aim of the study was the detection of atrial fibrillation with a special focus on other arrhythmias according to criteria defined in earlier clinical trials. METHODS We performed a retrospective analysis of 64 patients with cryptogenic stroke who underwent ILR implantation between 4/2014 and 1/2018. The primary endpoint was the detection of atrial fibrillation, significant bradycardia (<40 bpm) or tachycardia (>150 bpm). ILR interrogation was performed after implantation and 6, 12 and 24 months thereafter. RESULTS Mean patients age was 65.4 ± 12 years, 50% were male. Mean follow-up duration was 419.2 ± 309 days. One death occurred during follow-up. 23 patients (35.9%) experienced a symptomatic clinical neurological or cardiac event during follow-up. Overall rate of detected arrhythmias was 35% (23/64). The most frequent arrhythmia was atrial fibrillation which was observed in 16 patients (25%). 6 of 16 patients presenting with atrial fibrillation had no clinical symptoms. Bradycardias requiring subsequent pacemaker implantations were detected in 9.4%. A ventricular tachycardia was observed in one patient (1.6%). CONCLUSION In this group of patients with cryptogenic stroke the rate of arrhythmic events was high. Besides a high rate of atrial fibrillation (25%), an unexpectedly high rate of bradyarrhythmias (9.4%) occurred in our patient collective. Since many of those episodes were clinically asymptomatic, the ILR helps to detect and treat those clinically silent arrhythmias.
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Affiliation(s)
- Simon Pecha
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Germany.
| | - Iris Wilke
- Department of Cardiology, St. Adolf-Stift Hospital Reinbek, Germany
| | - Yalin Yildirim
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Germany
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29
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Cryptogenic stroke and atrial fibrillation in a real-world population: the role of insertable cardiac monitors. Sci Rep 2020; 10:3230. [PMID: 32094376 PMCID: PMC7040015 DOI: 10.1038/s41598-020-60180-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/24/2020] [Indexed: 12/16/2022] Open
Abstract
The incidence of atrial fibrillation (AF) in cryptogenic stroke (CS) patients has been studied in carefully controlled clinical trials, but real-world data are limited. We investigated the incidence of AF in clinical practice among CS patients with an insertable cardiac monitor (ICM) placed for AF detection. Patients with CS admitted to our Stroke Unit were included in the study; they received an ICM and were monitored for up to 3 years for AF detection. All detected AF episodes of at least 120 sec were considered. From March 2016 to March 2019, 58 patients (mean age 68.1 ± 9.3 years, 67% male) received an ICM to detect AF after a CS. No patients were lost to follow-up. AF was detected in 24 patients (41%, AF group mean age 70.8 ± 9.4 years, 62% male) after a mean time of 6 months from ICM (ranging from 2 days to 2 years) and 8 months after CS (ranging from 1 month to 2 years). In these AF patients, anticoagulant treatment was prescribed and nobody had a further stroke. In conclusion, AF episodes were detected via continuous monitoring with ICMs in 41% of implanted CS patients. AF in CS patients is asymptomatic and difficult to diagnose by strategies based on intermittent short-term recordings. Therefore, we suggest that ICMs should be part of daily practice in the evaluation of CS patients.
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30
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Rubio Campal JM, García Torres MA, Sánchez Borque P, Navas Vinagre I, Zamarbide Capdepón I, Miracle Blanco Á, Bravo Calero L, Sáez Pinel R, Tuñón Fernández J, Serratosa Fernández JM. Detecting Atrial Fibrillation in Patients With an Embolic Stroke of Undetermined Source (from the DAF-ESUS registry). Am J Cardiol 2020; 125:409-414. [PMID: 31780074 DOI: 10.1016/j.amjcard.2019.10.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/18/2019] [Accepted: 10/28/2019] [Indexed: 12/20/2022]
Abstract
Atrial fibrillation (AF) causes a substantial proportion of embolic strokes of undeterminded source (ESUS). Effective detection of subclinical AF (SCAF) has important therapeutic implications. We conducted a prospective study to determine the prevalence of SCAF in patients with ESUS through of a 21-day Holter monitoring. In an early-monitoring group, Holter was initiated immediately after hospital discharge. The results were compared with a previous cohort of patients in whom the Holter was initiated at least 1 week after hospital discharge (late-monitoring group). We included 100 patients (50 each group; 69 ± 13 years, 56% male). Mean time from ESUS to Holter was 1.2 ± 1 day in the early-monitoring group and 30 ± 15 days in the late-monitoring group. SCAF was detected in 22% of patients in the early-monitoring and 6% in the late-monitoring group (p <0.05). Patients with SCAF were older (77 ± 9 vs 67 ± 11 years, p <0.05), with a higher rate of left atrial enlargement (50% vs 20%, p<0.05), renal impairment (28% vs 5%; p<0.01), and a slower mean heart rate (55 ± 6 vs 70 ± 6 beats/min; p<0.001). On multivariate analysis, the presence of persistent bradycardia (≤60 beats/min) in the 21-day Holter was a powerful and significant risk factor for SCAF. In conclusion, the sooner 21-day Holter electrocardiogram monitoring is initiated after ESUS, the more likely SCAF can be detected. Sinus bradycardia is a powerful predictor of SCAF in patients with ESUS.
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31
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Mentel A, Quinn TJ, Cameron AC, Lees KR, Abdul-Rahim AH. The impact of atrial fibrillation type on the risks of thromboembolic recurrence, mortality and major haemorrhage in patients with previous stroke: A systematic review and meta-analysis of observational studies. Eur Stroke J 2020; 5:155-168. [PMID: 32637649 DOI: 10.1177/2396987319896674] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 12/03/2019] [Indexed: 11/15/2022] Open
Abstract
Introduction There is conflicting evidence on the impact of atrial fibrillation (AF) type, i.e. non-paroxysmal AF or paroxysmal AF, on thromboembolic recurrence. The consensus of risk equivalence is greatly based on historical evidence, focussing on initial stroke risks. We conducted a systematic review and meta-analysis to describe the impact of AF type on the risk of thromboembolic recurrence, mortality and major haemorrhage in patients with previous stroke. Methods We systematically searched four multidisciplinary databases from inception to December 2018. We selected observational studies investigating clinical outcomes in patients with ischaemic stroke and AF, stratified by AF type. We assessed all included studies for risk of bias using the 'Risk of Bias In Non-randomised Studies - of Exposures' tool. The Comprehensive Meta-Analysis Software was used to calculate odds ratios from crude event rates. Results After reviewing 14,127 citations, we selected 108 studies for full-text screening. We extracted data from a total of 26 studies, reporting outcomes on 23,054 patients. Overall, risk of bias was moderate. The annual incidence rates of thromboembolism in patients with non-paroxysmal AF and paroxysmal AF were 7.1% (95% confidence interval: 4.2-11.7) and 5.2% (95% confidence interval: 3.2-8.2), respectively. The odds ratio for thromboembolism in patients with non-paroxysmal AF versus paroxysmal AF was 1.47 (95% confidence interval: 1.08-1.99, p = 0.013). The annual mortality rates in patients with non-paroxysmal AF and paroxysmal AF were 20.0% (95% confidence interval: 13.2-28.0) and 10.1% (95% confidence interval: 5.4-17.3), respectively, and odds ratio was 1.90 (95% confidence interval: 1.43-2.52, p < 0.001). There was no difference in rates of major haemorrhage, odds ratio = 1.01 (95% confidence interval: 0.61-1.69, p = 0.966). Conclusion In patients with prior stroke, non-paroxysmal AF is associated with significantly higher risk of thromboembolic recurrence and mortality than paroxysmal AF. Although current guidelines make no distinction between non-paroxysmal AF and paroxysmal AF for secondary stroke prevention, future guidance and risk stratification tools may need to consider this differential risk (PROSPERO ID: CRD42019118531).
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Affiliation(s)
- Antonia Mentel
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alan C Cameron
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kennedy R Lees
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Azmil H Abdul-Rahim
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
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32
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Edwards SJ, Wakefield V, Jhita T, Kew K, Cain P, Marceniuk G. Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation. Health Technol Assess 2020; 24:1-184. [PMID: 31944175 PMCID: PMC6983910 DOI: 10.3310/hta24050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Cryptogenic stroke is a stroke for which no cause is identified after standard diagnostic tests. Long-term implantable cardiac monitors may be better at diagnosing atrial fibrillation and provide an opportunity to reduce the risk of stroke recurrence with anticoagulants. OBJECTIVES The objectives were to assess the diagnostic test accuracy, clinical effectiveness and cost-effectiveness of three implantable monitors [BioMonitor 2-AF™ (Biotronik SE & Co. KG, Berlin, Germany), Confirm Rx™ (Abbott Laboratories, Lake Bluff, IL, USA) and Reveal LINQ™ (Medtronic plc, Minneapolis, MN, USA)] in patients who have had a cryptogenic stroke and for whom no atrial fibrillation is detected after 24 hours of external electrocardiographic monitoring. DATA SOURCES MEDLINE, EMBASE, The Cochrane Library, Database of Abstracts of Reviews of Effects and Health Technology Assessment databases were searched from inception until September 2018. REVIEW METHODS A systematic review was undertaken. Two reviewers agreed on studies for inclusion and performed quality assessment using the Cochrane Risk of Bias 2.0 tool. Results were discussed narratively because there were insufficient data for synthesis. A two-stage de novo economic model was developed: (1) a short-term patient flow model to identify cryptogenic stroke patients who have had atrial fibrillation detected and been prescribed anticoagulation treatment (rather than remaining on antiplatelet treatment) and (2) a long-term Markov model that captured the lifetime costs and benefits of patients on either anticoagulation or antiplatelet treatment. RESULTS One randomised controlled trial, Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL-AF) (Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-86), was identified, and no diagnostic test accuracy study was identified. The CRYSTAL-AF trial compared the Reveal™ XT (a Reveal LINQ predecessor) (Medtronic plc) monitor with standard of care monitoring. Twenty-six single-arm observational studies for the Reveal devices were also identified. The only data for BioMonitor 2-AF or Confirm Rx were from mixed population studies supplied by the companies. Atrial fibrillation detection in the CRYSTAL-AF trial was higher with the Reveal XT than with standard monitoring at all time points. By 36 months, atrial fibrillation was detected in 19% of patients with an implantable cardiac monitor and in 2.3% of patients receiving conventional follow-up. The 26 observational studies demonstrated that, even in a cryptogenic stroke population, atrial fibrillation detection rates are highly variable and most cases are asymptomatic; therefore, they probably would not have been picked up without an implantable cardiac monitor. Device-related adverse events, such as pain and infection, were low in all studies. The de novo economic model produced incremental cost effectiveness ratios comparing implantable cardiac monitors with standard of care monitoring to detect atrial fibrillation in cryptogenic stroke patients based on data for the Reveal XT device, which can be related to Reveal LINQ. The BioMonitor 2-AF and Confirm RX were included in the analysis by making a strong assumption of equivalence with Reveal LINQ. The results indicate that implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold. When each device is compared incrementally, BioMonitor 2-AF dominates Reveal LINQ and Confirm RX. LIMITATIONS The cost-effectiveness analysis for implantable cardiac monitors is based on a strong assumption of clinical equivalence and should be interpreted with caution. CONCLUSIONS All three implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold, compared with standard of care monitoring, for cryptogenic stroke patients with no atrial fibrillation detected after 24 hours of external electrocardiographic monitoring; however, further clinical studies are required to confirm their efficacy in cryptogenic stroke patients. STUDY REGISTRATION This study is registered as PROSPERO CRD42018109216. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steven J Edwards
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | | | - Tracey Jhita
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Kayleigh Kew
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Peter Cain
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
| | - Gemma Marceniuk
- British Medical Journal (BMJ) Technology Assessment Group, London, UK
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33
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Olsen FJ, Christensen LM, Krieger DW, Højberg S, Høst N, Karlsen FM, Svendsen JH, Christensen H, Biering-Sørensen T. Relationship between left atrial strain, diastolic dysfunction and subclinical atrial fibrillation in patients with cryptogenic stroke: the SURPRISE echo substudy. Int J Cardiovasc Imaging 2019; 36:79-89. [PMID: 31595399 DOI: 10.1007/s10554-019-01700-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/16/2019] [Indexed: 12/11/2022]
Abstract
Paroxysmal atrial fibrillation (PAF) may be the cause of a substantial part of cryptogenic strokes (CS). Echocardiography could assist risk stratification for PAF to select patients in need of prolonged rhythm monitoring. We aimed to assess the value of left atrial (LA) strain and a revised diastolic dysfunction (DDF) model with LA strain for predicting PAF. This was a prospective study of 56 CS patients who had a cardiac monitor implanted for 3 year monitoring for PAF, and an echocardiogram performed prior to monitoring. Conventional echocardiography, global longitudinal strain (GLS) and LA strain were performed. LA speckle tracking provided the LA reservoir strain (LAs). Patients were stratified into high versus low LAs by ROC curves (28.2%), and this cut-off was used to refine DDF grading. During follow-up of median 20 months, 13 (23%) patients were diagnosed with PAF. No conventional echocardiographic parameters differed between patients who developed PAF and those without PAF. However, LAs was significantly impaired in PAF patients (LAs: 30 vs. 27% for non-PAF and PAF, p = 0.046). Low LAs significantly predicted PAF independent of LA volume and GLS [OR 5.88 (1.30; 26.55), p = 0.021]. Revised DDF grading significantly predicted PAF, even when adjusted for the CHADS2 risk-score (OR 1.88 [1.01;3.50], per increase in DDF grade, p for trend = 0.047), which was not the case for conventional DDF grading. In conclusion, LAs associates with PAF independent of GLS and LA size, and may be used to improve the performance of DDF grading for identifying PAF in CS patients.
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Affiliation(s)
- Flemming J Olsen
- Cardiovascular Non-Invasive Imaging Research Laboratory (CIRL), Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.
| | - Louisa M Christensen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Derk W Krieger
- Comprehensive Stroke Center, Mediclinic City Hospital, Dubai, United Arab Emirates.,Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Søren Højberg
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nis Høst
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Finn M Karlsen
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jesper H Svendsen
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Cardiovascular Non-Invasive Imaging Research Laboratory (CIRL), Department of Cardiology, Herlev & Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Bertaglia E, Blank B, Blomström-Lundqvist C, Brandes A, Cabanelas N, Dan GA, Dichtl W, Goette A, de Groot JR, Lubinski A, Marijon E, Merkely B, Mont L, Piorkowski C, Sarkozy A, Sulke N, Vardas P, Velchev V, Wichterle D, Kirchhof P. Atrial high-rate episodes: prevalence, stroke risk, implications for management, and clinical gaps in evidence. Europace 2019; 21:1459-1467. [PMID: 31377792 PMCID: PMC6788209 DOI: 10.1093/europace/euz172] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/15/2019] [Indexed: 12/20/2022] Open
Abstract
Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10-30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.
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Affiliation(s)
- Emanuele Bertaglia
- Department of Cardiac, Vascular and Thoracic Sciences, Azienda Ospedaliera, Padua, Italy
| | | | | | - Axel Brandes
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Nuno Cabanelas
- Arrhythmias Unit of Cardiology Department, Hospital Prof. Dr. Fernando Fonseca, Amadora-Sintra, Portugal
| | - G -Andrei Dan
- Colentina University Hospital, Medicine University “Carol Davila”, Bucharest, Romania
| | - Wolfgang Dichtl
- University Hospital of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- St. Vincenz Hospital Paderborn, Cardiology and Intensive Care Medicine, Paderborn, Germany
| | - Joris R de Groot
- Department of Cardiology, Heart Center, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Andrzej Lubinski
- Department of Interventional Cardiology and Arrhythmias, Medical University of Lodz, Lodz, Poland
| | - Eloi Marijon
- Cardiac Electrophysiology Section, European Georges Pompidou Hospital, Paris, France
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University Budapest, Budapest, Hungary
| | - Lluis Mont
- Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain
| | | | | | - Neil Sulke
- Eastbourne District General Hospital, Eastbourne, UK
| | - Panos Vardas
- Heart Sector, Hygeia Group Hospitals, Athens, Greece
| | - Vasil Velchev
- Cardiology Clinic, St. Anna University Hospital, Medical University Sofia, Sofia, Bulgaria
| | - Dan Wichterle
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals NHS Trusts, IBR 126a, Wolfson Drive, Birmingham B15 2TT, UK
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35
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Cuadrado-Godia E, Benito B, Ois A, Vallès E, Rodríguez-Campello A, Giralt-Steinhauer E, Cabrera S, Alcalde O, Jiménez-López J, Jiménez-Conde J, Martí-Almor J, Roquer J. Ultra-early continuous cardiac monitoring improves atrial fibrillation detection and prognosis of patients with cryptogenic stroke. Eur J Neurol 2019; 27:244-250. [PMID: 31424609 DOI: 10.1111/ene.14061] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 07/22/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE Subclinical atrial fibrillation (AF) is known to underlie a number of cases of cryptogenic stroke (CrS). However, there is need to define the most effective strategy for AF detection. The diagnostic usefulness was analysed of a strategy based on ultra-early continuous monitoring in patients with CrS in terms of AF detection, oral anticoagulation treatment and stroke recurrence, in comparison to a standard outpatient strategy. METHODS Patients with ischaemic stroke of undetermined origin and confirmed to be cryptogenic after extensive work-up were searched for AF with (i) a conventional strategy (historical cohort, n = 101) with serial electrocardiograms and 24-h Holter monitoring or (ii) an ultra-early monitoring strategy with insertable cardiac monitor (ICM) implanted before discharge (prospective cohort, n = 90). AF episodes lasting >1 min, anticoagulant treatment and stroke recurrence were recorded. RESULTS During admission, AF was similarly detected in both cohorts (24% of patients). After discharge (mean follow-up 30 ± 10 months), AF detection rates were 17/80 (21.3%) and 38/65 (58.5%) for patients in the conventional versus the ultra-early ICM group (P < 0.001). Up to 41% of AF cases in the ICM cohort were detected within the first month. Oral anticoagulation was initiated in 37.6% versus 65.5% (P < 0.001) and stroke recurrence was recorded in 10.9% versus 3.3% (P 0.04) in the conventional versus the ICM cohort. CONCLUSIONS Pre-discharge ICM implant allows detection of AF during follow-up in up to 58% of selected patients with CrS. Compared to a conventional strategy, ultra-early ICM implant results in higher anticoagulation rates and a decrease in stroke recurrence.
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Affiliation(s)
- E Cuadrado-Godia
- Neurology Department, Hospital del Mar. Group of Research on Neurovascular Diseases, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - B Benito
- Cardiology Department, Hospital del Mar. Group of Biomedical Research in Heart Diseases, Hospital del Mar Medical Research Institute, Barcelona, Spain.,Cardiology Department, Hospital Vall d'Hebron. Vascular Biology and Metabolism Program, Vall d'Hebron Research Institute, Barcelona, Spain
| | - A Ois
- Neurology Department, Hospital del Mar. Group of Research on Neurovascular Diseases, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - E Vallès
- Cardiology Department, Hospital del Mar. Group of Biomedical Research in Heart Diseases, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - A Rodríguez-Campello
- Neurology Department, Hospital del Mar. Group of Research on Neurovascular Diseases, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - E Giralt-Steinhauer
- Neurology Department, Hospital del Mar. Group of Research on Neurovascular Diseases, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - S Cabrera
- Cardiology Department, Hospital Joan XXIII, Tarragona, Spain
| | - O Alcalde
- Cardiology Department, Complejo Universitario de Navarra, Pamplona, Spain
| | - J Jiménez-López
- Cardiology Department, Hospital del Mar. Group of Biomedical Research in Heart Diseases, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - J Jiménez-Conde
- Neurology Department, Hospital del Mar. Group of Research on Neurovascular Diseases, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - J Martí-Almor
- Cardiology Department, Hospital del Mar. Group of Biomedical Research in Heart Diseases, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | - J Roquer
- Neurology Department, Hospital del Mar. Group of Research on Neurovascular Diseases, Hospital del Mar Medical Research Institute, Barcelona, Spain
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Tsivgoulis G, Katsanos AH, Köhrmann M, Caso V, Perren F, Palaiodimou L, Deftereos S, Giannopoulos S, Ellul J, Krogias C, Mavridis D, Triantafyllou S, Alexandrov AW, Schellinger PD, Alexandrov AV. Duration of Implantable Cardiac Monitoring and Detection of Atrial Fibrillation in Ischemic Stroke Patients: A Systematic Review and Meta-Analysis. J Stroke 2019; 21:302-311. [PMID: 31590474 PMCID: PMC6780018 DOI: 10.5853/jos.2019.01067] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 06/04/2019] [Accepted: 06/14/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Current guidelines do not provide firm directions on atrial fibrillation (AF) screening after ischemic stroke (IS). We sought to investigate the association of implantable cardiac monitoring (ICM) duration with the yield of AF detection in IS patients. METHODS We included studies reporting AF detection rates by ICM in IS patients with negative initial AF screening. We excluded studies reporting prolonged cardiac monitoring with devices other than ICM, not providing AF detection rates or monitoring duration, and reporting overlapping data for the same population. The random-effects model was used for all pooled estimates and meta-regression analyses. RESULTS We included 28 studies (4,531 patients, mean age 65 years). In meta-regression analyses, the proportion of AF detection by ICM was independently associated with monitoring duration (coefficient=0.015; 95% confidence interval [CI], 0.005 to 0.024) and mean patient age (coefficient=0.009; 95% CI, 0.003 to 0.015). No associations were detected with other patient characteristics, including IS subtype (cryptogenic vs. embolic stroke of undetermined source) or time from IS onset to CM implantation. In subgroup analyses, significant differences (P<0.001) in the AF detection rates were found for ICM duration (<6 months: 5% [95% CI, 3% to 6%]; ≥6 and ≤12 months: 21% [95% CI, 16% to 25%]; >12 and ≤24 months: 26% [95% CI, 22% to 31%]; >24 months: 34% [95% CI, 29% to 39%]). CONCLUSION s Extended duration of ICM monitoring and increased patient age are factors that substantially increase AF detection in IS patients with initial negative AF screening.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aristeidis H. Katsanos
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Martin Köhrmann
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Valeria Caso
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Fabienne Perren
- Department of Neurology, University Hospital of Geneva, Geneva, Switzerland
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Deftereos
- Second Department of Cardiology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany
| | - Dimitris Mavridis
- Department of Primary Education, University of Ioannina, Ioannina, Greece
| | - Sokratis Triantafyllou
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anne W. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter D. Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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Göksu EÖ, Yüksel B, Esin M, Küçükseymen E, Ünal A, Genç A, Yaman A. The value of STAF (Score for the Targeting of Atrial Fibrillation) in Patients with Cryptogenic Embolic Stroke. ACTA ACUST UNITED AC 2019; 56:119-122. [PMID: 31223244 DOI: 10.5152/npa.2017.19348] [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] [Received: 09/27/2016] [Accepted: 01/02/2017] [Indexed: 11/22/2022]
Abstract
Introduction The aim of the present study was to predict paroxysmal atrial fibrillation (PAF) in acute ischemic stroke patients with presumed cryptogenic embolic etiology. Methods In this retrospective cohort study, demographics, blood tests, data of neuroimaging studies such as non-contrast computed tomography (NCCT), magnetic resonance imaging (MRI), standard 12-lead electrocardigraphy (ECG), 24-hour Holter ECG, echocardiography was collected. The diagnostic work-up to detect atrial fibrillation (AF) was either medical history of the patient or 12-lead ECG or 24-hour Holter ECG or continuous ECG monitoring. Score for the targeting of atrial fibrillation (STAF) was calculated for all patients. Cryptogenic ischemic stroke (CS) patients with and without documented AF were recorded. Results Between July 2014 and December 2015, a total of 133 of the 258 patients with CS were included in this study. Overall, 133 patients were enrolled and AF was detected in 30 (22.6%) patients. In univariate analysis gender (p<0.001), age (p=0.001), smoking habit (p=0.004), aortic and mitral valve insufficiency (p=0.014 and p=0.021), left ventricular systolic dysfunction (p=0.04), and left atrial dilatation (p=0.03) were predictors of AF but multivariate analysis showed that only gender and age were independent predictors of AF in patients with presumed cryptogenic ischemic stroke. According to ROC analysis, area under the curve was 70% and the sensitivity and specificity of STAF score of ≥5 was 86% and 71% respectively. Conclusion STAF score predicted with fair accuracy, and has a limited use for the risk of PAF in stroke patients.
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Affiliation(s)
| | - Burcu Yüksel
- Antalya Research and Training Hospital, Neurology Clinic, Antalya, Turkey
| | - Murat Esin
- Antalya Research and Training Hospital, Cardiology Clinic, Antalya, Turkey
| | - Elif Küçükseymen
- Antalya Research and Training Hospital, Neurology Clinic, Antalya, Turkey
| | - Ali Ünal
- Neurology Department, Akdeniz University School of Medicine, Antalya, Turkey
| | - Ahmet Genç
- Antalya Research and Training Hospital, Cardiology Clinic, Antalya, Turkey
| | - Aylin Yaman
- Antalya Research and Training Hospital, Neurology Clinic, Antalya, Turkey
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Abstract
Background The pattern of stroke in rural population differs from that in urban ones. Although there are many studies on this condition in sub-Saharan Africa, few studies about stroke pattern in a Kenyan rural area exist.. This study therefore aims at describing the characteristics of stroke in a rural Kenyan hospital. Patients and Methods The study was conducted on 227 consecutive patients admitted with a World Health Organization (WHO) diagnosis of stroke in Kangundo Hospital, a level IV facility in Machakos, Eastern Kenya, between April 2015 and September 2016. The sub-type and anatomical distribution of stroke as well as the age, gender of the patients were recorded prospectively. Diagnosis was made through physical neurological examination and confirmed by Computerized Tomography (CT) scan imaging. Only those with complete bio-data, past medical and social history, clinical and physical findings of the patients and imaging results were included. The data were entered into a pre-formatted questionnaire, analysed for means, standard deviations and frequencies, and are presented in tables and bar charts. Results Out of 3200 medical admissions, 227 (7.09%) had a confirmed diagnosis of stroke. Ischaemic stroke was more common (67.4%) than haemorrhagic stroke (32.6%). It affected mainly the anterior circulation, especially the middle cerebral artery (39%). The mean age of patients was 68.8 years, (Range 32–96). It was more common in females (62%) than in males (38%). Hypertension was the most common (74%) risk factor followed by alcohol abuse (63%), tobacco smoking (48%) and diabetes mellitus (42%). Conclusion Ischaemic stroke was the more common major cause of morbidity in the rural hospital studied in Kenya. It occurred most commonly among elderly females, with the most frequent comorbidities being hypertension. In addition, modifiable lifestyle factors like alcohol abuse and cigarette smoking contributed to the prevalence; hence we recommend the control of blood pressure and glucose as well as lifestyle modification to reduce the scourge in our studied population.
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Tsivgoulis G, Katsanos AH, Köhrmann M, Caso V, Lemmens R, Tsioufis K, Paraskevas GP, Bornstein NM, Schellinger PD, Alexandrov AV, Krogias C. Embolic strokes of undetermined source: theoretical construct or useful clinical tool? Ther Adv Neurol Disord 2019; 12:1756286419851381. [PMID: 31205494 PMCID: PMC6535711 DOI: 10.1177/1756286419851381] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 04/28/2019] [Indexed: 11/30/2022] Open
Abstract
In 2014, the definition of embolic strokes of undetermined source (ESUS) emerged as a new clinical construct to characterize cryptogenic stroke (CS) patients with complete vascular workup to determine nonlacunar, nonatherosclerotic strokes of presumable embolic origin. NAVIGATE ESUS, the first phase III randomized-controlled, clinical trial (RCT) comparing rivaroxaban (15 mg daily) with aspirin (100 mg daily), was prematurely terminated for lack of efficacy after enrollment of 7213 patients. Except for the lack of efficacy in the primary outcome, rivaroxaban was associated with increased risk of major bleeding and hemorrhagic stroke compared with aspirin. RE-SPECT ESUS was the second phase III RCT that compared the efficacy and safety of dabigatran (110 or 150 mg, twice daily) to aspirin (100 mg daily). The results of this trial have been recently presented and showed similar efficacy and safety outcomes between dabigatran and aspirin. Indirect analyses of these trials suggest similar efficacy on the risk of ischemic stroke (IS) prevention, but higher intracranial hemorrhage risk in ESUS patients receiving rivaroxaban compared to those receiving dabigatran (indirect HR = 6.63, 95% CI: 1.38-31.76). ESUS constitute a heterogeneous group of patients with embolic cerebral infarction. Occult AF represents the underlying mechanism of cerebral ischemia in the minority of ESUS patients. Other embolic mechanisms (paradoxical embolism via patent foramen ovale, aortic plaque, nonstenosing unstable carotid plaque, etc.) may represent alternative mechanisms of cerebral embolism in ESUS, and may mandate different management than oral anticoagulation. The potential clinical utility of ESUS may be challenged since the concept failed to identify patients who would benefit from anticoagulation therapy. Compared with the former diagnosis of CS, ESUS patients required thorough investigations; more comprehensive diagnostic work-up than is requested in current ESUS diagnostic criteria may assist clinicians in uncovering the source of brain embolism in CS patients and individualize treatment approaches.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, USA
| | - Aristeidis H. Katsanos
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
- Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Germany
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - Robin Lemmens
- Division of Experimental Neurology, Department of Neurosciences, Catholic University (KU) Leuven-University, Belgium, Flemish Institute for Biotechnology (VIB), Center for Brain and Disease Research, Laboratory of Neurobiology, Leuven, Belgium, and Department of Neurology, University Hospitals Leuven, Belgium
| | - Konstantinos Tsioufis
- First Cardiology Clinic, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Greece
| | - George P. Paraskevas
- First Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Natan M. Bornstein
- Shaare Zedek Medical Center, Jerusalem, and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Peter D. Schellinger
- Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, USA
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Gudrunstr.56, Bochum, 44791, Germany
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Scacciatella P, Jorfida M, Biava LM, Meynet I, Zema D, D’Ascenzo F, Pristipino C, Cerrato P, Giustetto C, Gaita F. Insertable cardiac monitor detection of silent atrial fibrillation in candidates for percutaneous patent foramen ovale closure. J Cardiovasc Med (Hagerstown) 2019; 20:290-296. [DOI: 10.2459/jcm.0000000000000790] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Zhao SX, Ziegler PD, Crawford MH, Kwong C, Koehler JL, Passman RS. Evaluation of a clinical score for predicting atrial fibrillation in cryptogenic stroke patients with insertable cardiac monitors: results from the CRYSTAL AF study. Ther Adv Neurol Disord 2019; 12:1756286419842698. [PMID: 31007721 PMCID: PMC6460885 DOI: 10.1177/1756286419842698] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 03/14/2019] [Indexed: 12/13/2022] Open
Abstract
Background The HAVOC score was previously developed to predict the risk of atrial fibrillation (AF) after cryptogenic stroke (CS) or transient ischemic attack (TIA). The purpose of this study was to apply the HAVOC score to patients who received insertable cardiac monitors (ICMs) in the CRYSTAL AF study. Methods All patients from the CRYSTAL AF study who received an ICM were included. HAVOC score (one point each for peripheral vascular disease and obesity with body mass index >30, two points each for hypertension, age ⩾ 75, valvular heart disease, and coronary artery disease, 4 points for congestive heart failure) was computed for all patients. The primary endpoint was AF detection by 12 months of ICM monitoring. Results A total of 214 patients who received ICM were included. AF was detected in 40 patients while the remaining 174 patients were AF negative. The HAVOC score was significantly higher among patients with AF [median 3.0 with interquartile range (IQR) 2-4] than those without AF [median 2.0 (IQR 0-3)], p = 0.01. AF increased significantly across the three HAVOC score groups: 11% in Group A (score 0-1), 18% in Group B (score 2-3), and 32 % in Group C (score ⩾ 4) with p = 0.02. Conclusions The HAVOC score was shown in this post hoc analysis of CRYSTAL AF to successfully stratify AF risk post CS or TIA. The 11% AF rate in the lowest HAVOC score group highlights the significance of nontraditional contributors to AF and ischemic stroke.
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Affiliation(s)
- Susan X Zhao
- Division of Cardiology, Santa Clara Valley Medical Center, 751 S. Bascom Avenue, Suite # 340, San Jose, CA 95128, USA
| | | | - Michael H Crawford
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Rod S Passman
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Petryszyn P, Niewinski P, Staniak A, Piotrowski P, Well A, Well M, Jeskowiak I, Lip G, Ponikowski P. Effectiveness of screening for atrial fibrillation and its determinants. A meta-analysis. PLoS One 2019; 14:e0213198. [PMID: 30893323 PMCID: PMC6426211 DOI: 10.1371/journal.pone.0213198] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 02/16/2019] [Indexed: 11/19/2022] Open
Abstract
Background Many atrial fibrillation patients eligible for oral anticoagulants are unaware of the presence of AF, and improved detection is necessary to facilitate thromboprophylaxis against stroke. Objective To assess the effectiveness of screening for AF compared to no screening and to compare efficacy outcomes of different screening strategies. Materials and methods Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE from Jan 1, 2000 –Dec 31, 2015 were searched. Studies employing systematic or opportunistic screening and using ECG or pulse palpation in populations age ≥40 years were included. Data describing study and patient characteristics and number of patients with new AF were extracted. The outcome was the incidence of previously undiagnosed AF. Results We identified 25 unique (3 RCTs and 22 observational) studies (n = 88 786) from 14 countries. The incidence of newly detected AF due to screening was 1.5% (95% CI 1.1 to 1.8%). Systematic screening was more effective than opportunistic: 1.8% (95% CI 1.4 to 2.3%) vs. 1.1% (95% CI 0.6 to 1.6%), p<0.05, GP-led screening than community based: 1.9% (95% CI 1.4 to 2.4%) vs. 1.1% (95% CI 0.7 to 1.6%), p<0.05, and repeated heart rhythm measurements than isolated assessments of rhythm: 2.1% (95% CI 1.5–2.8) vs. 1.2% (95% CI 0.8–1.6), p<0.05. Only heart rhythm measurement frequency had statistical significance in a multivariate meta-regression model (p<0.05). Conclusions Active screening for AF, whether systematic or opportunistic, is effective beginning from 40 years of age. The organisation of screening process may be more important than technical solutions used for heart rhythm assessment.
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Affiliation(s)
- Pawel Petryszyn
- Department of Clinical Pharmacology, Wroclaw Medical University, Wroclaw, Poland
- * E-mail:
| | - Piotr Niewinski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Aleksandra Staniak
- Department of Clinical Pharmacology, Wroclaw Medical University, Wroclaw, Poland
| | - Patryk Piotrowski
- Department of Psychiatry, Wroclaw Medical University, Wroclaw, Poland
| | - Anna Well
- Department of Clinical Pharmacology, Wroclaw Medical University, Wroclaw, Poland
| | - Michal Well
- Department of Clinical Pharmacology, Wroclaw Medical University, Wroclaw, Poland
| | - Izabela Jeskowiak
- Department of Clinical Pharmacology, Wroclaw Medical University, Wroclaw, Poland
| | - Gregory Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
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Ratajczak-Tretel B, Lambert AT, Johansen H, Halvorsen B, Bjerkeli V, Russell D, Sandset EC, Ihle-Hansen H, Eriksen E, Næss H, Novotny V, Khanevski AN, Truelsen TC, Idicula T, Ægidius KL, Tobro H, Krogseth SB, Ihle-Hansen H, Hagberg G, Kruuse C, Arntzen K, Bakkejord GK, Villseth M, Nakstad I, Eldøen G, Shafiq R, Gulsvik A, Kurz M, Rezai M, Sømark J, Tingvoll SH, Jonassen C, Ingebrigtsen S, Steffensen LH, Kremer C, Atar D, Aamodt AH. Atrial fibrillation in cryptogenic stroke and transient ischaemic attack - The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study: Rationale and design. Eur Stroke J 2019; 4:172-180. [PMID: 31259265 DOI: 10.1177/2396987319837089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 02/13/2019] [Indexed: 01/01/2023] Open
Abstract
Purpose Paroxysmal atrial fibrillation is often suspected as a probable cause of cryptogenic stroke. Continuous long-term ECG monitoring using insertable cardiac monitors is a clinically effective technique to screen for atrial fibrillation and superior to conventional follow-up in cryptogenic stroke. However, more studies are needed to identify factors which can help selecting patients with the highest possibility of detecting atrial fibrillation with prolonged rhythm monitoring. The clinical relevance of short-term atrial fibrillation, the need for medical intervention and the evaluation as to whether intervention results in improved clinical outcomes should be assessed. Method The Nordic Atrial Fibrillation and Stroke Study is an international, multicentre, prospective, observational trial evaluating the occurrence of occult atrial fibrillation in cryptogenic stroke and transient ischaemic attack. Patients with cryptogenic stroke or transient ischaemic attack from the Nordic countries are included and will have the Reveal LINQ® Insertable cardiac monitor system implanted for 12 months for atrial fibrillation detection. Biomarkers which can be used as predictors for atrial fibrillation and may identify patients, who could derive the most clinical benefit from the detection of atrial fibrillation by prolonged monitoring, are being studied. Conclusion The primary endpoint is atrial fibrillation burden within 12 months of continuous rhythm monitoring. Secondary endpoints are atrial fibrillation burden within six months, levels of biomarkers predicting atrial fibrillation, CHA2DS2-VASc score, incidence of recurrent stroke or transient ischaemic attack, use of anticoagulation and antiarrhythmic drugs, and quality of life measurements. The clinical follow-up period is 12 months. The study started in 2017 and the completion is expected at the end of 2020.
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Affiliation(s)
- Barbara Ratajczak-Tretel
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anna Tancin Lambert
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Bente Halvorsen
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Vigdis Bjerkeli
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - David Russell
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Hege Ihle-Hansen
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Erik Eriksen
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Vojtech Novotny
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Thomas C Truelsen
- Department of Neurology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Titto Idicula
- Department of Neurology, St. Olav University Hospital, Trondheim, Norway
| | - Karen L Ægidius
- Department of Neurology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Håkon Tobro
- Department of Neurology, Telemark Hospital, Skien, Norway
| | - Siv B Krogseth
- Department of Neurology, Vestfold Hospital, Tønsberg, Norway
| | - Håkon Ihle-Hansen
- Department of Internal Medicine, Vestre Viken Hospital Trust, Bærum Hospital, Bærum, Norway
| | - Guri Hagberg
- Department of Internal Medicine, Vestre Viken Hospital Trust, Bærum Hospital, Bærum, Norway
| | - Christina Kruuse
- Department of Neurology, Herlev Gentofte Hospital, Copenhagen, Denmark
| | | | | | - Maja Villseth
- Department of Neurology, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Ingvild Nakstad
- Department of Neurology, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | | | - Raheel Shafiq
- Department of Neurology, Molde Hospital, Molde, Norway
| | - Anne Gulsvik
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Martin Kurz
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Mehdi Rezai
- Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Jesper Sømark
- Department of Neurology, Innlandet Hospital Trust, Lillehammer, Norway
| | | | - Christine Jonassen
- Center of Laboratory Medicine, Østfold Hospital Trust, Grålum, Norway.,Department of Chemistry, Biotechnology and Food Science, Norwegian University of Life Sciences, Ås, Norway
| | | | | | - Christine Kremer
- Department of Neurology, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology B, Oslo University Hospital, Ullevål, Oslo, Norway
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Hyman DA, Siebert V, Jia X, Alam M, Levine GN, Virani SS, Birnbaum Y. Risk Assessment of Stroke in Patients with Atrial Fibrillation: Current Shortcomings and Future Directions. Cardiovasc Drugs Ther 2019; 33:105-117. [PMID: 30684116 DOI: 10.1007/s10557-018-06849-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation is a well-known risk factor for cardioembolic stroke; a number of risk stratification scoring systems have been developed to help differentiate which patients would stand to benefit from anticoagulation. However, these scoring systems cannot be utilized in patients whose atrial fibrillation has not been diagnosed. As implantable cardiac monitors become more prevalent, it becomes possible to identify occult, subclinical atrial fibrillation. With this data, it is also possible to examine the relationship between episodes of paroxysmal atrial fibrillation and thromboembolism and the total burden of paroxysmal atrial fibrillation and thromboembolic risk. The data gleaned from these devices provides insight and raises questions regarding the underlying mechanism of thromboembolism in atrial fibrillation, and in doing so, exposes shortcomings in the present clinical use of current risk scoring systems, specifically, the inability to account for atrial fibrillation burden and to apply scores at all in subclinical atrial fibrillation.
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Affiliation(s)
- Daniel A Hyman
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Vincent Siebert
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Xiaoming Jia
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mahboob Alam
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Glenn N Levine
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - Salim S Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Pristipino C, Sievert H, D'Ascenzo F, Mas JL, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EUROINTERVENTION 2019; 14:1389-1402. [PMID: 30141306 DOI: 10.4244/eij-d-18-00622] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
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Chen X, Luo W, Li J, Li M, Wang L, Rao Y, Li B, Zeng W. Diagnostic accuracy of STAF, LADS, and iPAB scores for predicting paroxysmal atrial fibrillation in patients with acute cerebral infarction. Clin Cardiol 2018; 41:1507-1512. [PMID: 30251368 DOI: 10.1002/clc.23080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/17/2018] [Accepted: 09/20/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The scoring scales scoring system for targeting atrial fibrillation (STAF), left atrial diameter, age, diagnosis of stroke, and smoking status (LADS), and identified by past history of arrhythmia or antiarrhythmic agent use, atrial dilation, and elevation of Brain natriuretic peptide (iPAB) have been proposed for predicting atrial fibrillation in patients with acute cerebral infarction, but their relative accuracies are not clear. This prospective study compared STAF, LADS, and iPAB scores for predicting paroxysmal atrial fibrillation (PAF) in patients with acute cerebral infarction. METHODS Patients with acute cerebral infarction (n = 744; 495 men, 249 women; aged 65 ± 12 years) were consecutively enrolled throughout the year 2016 at the Department of Neurology of Huizhou Municipal Central Hospital. Patients were followed for 3 months. The sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and best cutoff points of STAF, LADS, and iPAB scores for predicting PAF were computed. RESULTS Among the 744 patients, 37 patients had PAF. The AUCs of the STAF, LADS, and iPAB scores for predicting PAF were 0.87, 0.79, and 0.84, respectively, and with a cutoff at four points, the sensitivities were 73%, 70.3%, and 83.8%, and specificities were 92.1%, 82.2%, and 77%. CONCLUSIONS The STAF, LADS, and iPAB scores could satisfactorily predict PAF in patients with acute cerebral infarction. STAF was superior to the others in diagnostic performance.
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Affiliation(s)
- Xingdong Chen
- Department of Neurology, Huizhou Affiliated Hospital of Guangdong Medical University, Huizhou Municipal Central Hospital, Huizhou, China
| | - Weiliang Luo
- Department of Neurology, Huizhou Affiliated Hospital of Guangdong Medical University, Huizhou Municipal Central Hospital, Huizhou, China
| | - Jiming Li
- Department of Neurology, Huizhou Affiliated Hospital of Guangdong Medical University, Huizhou Municipal Central Hospital, Huizhou, China
| | - Mei Li
- Department of Neurology, Huizhou Affiliated Hospital of Guangdong Medical University, Huizhou Municipal Central Hospital, Huizhou, China
| | - Lizhi Wang
- Department of Neurology, Huizhou Affiliated Hospital of Guangdong Medical University, Huizhou Municipal Central Hospital, Huizhou, China
| | - Yu Rao
- Department of Neurology, Huizhou Affiliated Hospital of Guangdong Medical University, Huizhou Municipal Central Hospital, Huizhou, China
| | - Bosheng Li
- Department of Neurology, Huizhou Affiliated Hospital of Guangdong Medical University, Huizhou Municipal Central Hospital, Huizhou, China
| | - Wei Zeng
- Department of Neurology, Huizhou Affiliated Hospital of Guangdong Medical University, Huizhou Municipal Central Hospital, Huizhou, China
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Giancaterino S, Lupercio F, Nishimura M, Hsu JC. Current and Future Use of Insertable Cardiac Monitors. JACC Clin Electrophysiol 2018; 4:1383-1396. [DOI: 10.1016/j.jacep.2018.06.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/31/2018] [Accepted: 06/04/2018] [Indexed: 01/31/2023]
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Abstract
Atrial fibrillation is a common arrhythmia that is associated with increased risk of stroke, which can be reduced with appropriate anticoagulation treatment. However, it remains underdiagnosed in contemporary clinical practice using conventional detection methods, resulting in missed opportunities to implement appropriate treatment. Newer technologies developed in recent years can potentially enhance the detection of atrial fibrillation and overcome certain limitations of the conventional methods. However, uncertainties remain about their use and the significance of atrial fibrillation detected by some of these newer technologies. This review examines the evidence supporting the use of some of these technologies and evaluates their applications in certain clinical scenarios.
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Affiliation(s)
- Nath Zungsontiporn
- UT Southwestern Medical Center, Department of Internal Medicine, Division of Cardiology, Dallas, TX, USA
| | - Mark S Link
- UT Southwestern Medical Center, Department of Internal Medicine, Division of Cardiology, Dallas, TX, USA
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Bettin M, Dechering D, Kochhäuser S, Bode N, Eckardt L, Frommeyer G, Reinke F. Extended ECG monitoring with an implantable loop recorder in patients with cryptogenic stroke: time schedule, reasons for explantation and incidental findings (results from the TRACK-AF trial). Clin Res Cardiol 2018; 108:309-314. [PMID: 30167809 DOI: 10.1007/s00392-018-1358-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Implantable loop recorders (ILR) may be used to detect occult atrial fibrillation (AF) in patients with cryptogenic stroke. At present, there has been no description on the incidental findings of stored episodes in these patients. Furthermore, no standard practice has been established with respect to the duration of continued ECG monitoring in these patients. MATERIALS AND METHODS In the prospective monocentric study (TRACK-AF), a total of 173 patients with cryptogenic stroke received an ILR for detection of AF between November 2010 and December 2014. Before implantation all patients had undergone recommended protocols for detection of stroke causes. RESULTS During a mean follow-up of 24.8 ± 11.5 months, atrial tachyarrhythmias were detected in n = 33 pts (19.1%). Diagnosis of AF was made after a mean of 10.7 ± 11.4 months, time to first AF detection ranged between 0.2 and 39.8 months. In 15 patients (8.7%), other incidental findings were stored in the ILR memory. Short episodes of sinus arrest at night not requiring a permanent pacemaker were present in 8 pts (4.6%). DDD-pacemaker implantation due to sinus arrest or symptomatic bradyarrhythmias occurred in 5 patients (2.9%) after a median monitoring period of 23.1 ± 7.4 months. Further incidental findings were atrial flutter and an AV-nodal-reentry tachycardia in one patient, respectively. Both patients underwent successful catheter ablation. So far, ILR were explanted in 111 pts, and 71 ILR were explanted before end of service status of the battery. Main reason for ILR explantation was patients' preference (51%), followed by battery depletion (24%) and diagnosis of AF (15%). CONCLUSION The present study revealed a significant number of ECG findings during continued ECG monitoring for AF in patients with cryptogenic stroke. Apart from AF (17.5% during the first 1.5 years), other clinical relevant arrhythmias requiring, e.g., pacemaker implantations, were observed. With respect to these findings, we recommend to extend ILR monitoring to the end of battery life. However, acceptance of continued ECG monitoring until battery depletion was poor; in 71 patients (64%), the ILR were explanted before the end of battery life. TRIAL REGISTRATION Registered at ClinicalTrials.gov: NCT02641678.
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Affiliation(s)
- Markus Bettin
- Department of Cardiology II-Electrophysiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
| | - Dirk Dechering
- Department of Cardiology II-Electrophysiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
| | - Simon Kochhäuser
- Department of Cardiology II-Electrophysiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
| | - Niklas Bode
- Department of Cardiology II-Electrophysiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
| | - Lars Eckardt
- Department of Cardiology II-Electrophysiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II-Electrophysiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany.
| | - Florian Reinke
- Department of Cardiology II-Electrophysiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany
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Sanna T. Long-term monitoring to detect atrial fibrillation with the indwelling implantable cardiac monitors. Int J Stroke 2018; 13:893-904. [PMID: 30091680 DOI: 10.1177/1747493018790023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
An increasing number of detection tools are available and several detection strategies have been described to pursue the diagnosis of atrial fibrillation to prevent ischemic stroke. Monitoring tools include standard electrocardiography, snapshot single-lead recordings with professional or personal devices (e.g. smartphone-based), Holter monitor, external devices with long-term recording capabilities, and cardiac implantable electronic devices, including pacemakers, implantable cardioverter defibrillators and insertable cardiac monitors. Insertable cardiac monitors have shown high sensitivity and specificity for the detection of atrial fibrillation, allow up to three years of continuous monitoring, do not require cooperation of the patient, are well tolerated, have a short device-related time delay between detection of atrial fibrillation and notification to the physician, provide information on atrial fibrillation burden and are minimally invasive. On the other hand, insertable cardiac monitors require a considerable use of resources to process the recordings and have a significant initial cost. Studies conducted with insertable cardiac monitors on patients with prior stroke and on patients with risk factors for stroke but no prior cerebrovascular events or atrial fibrillation have consistently shown a measurable incidence of atrial fibrillation at follow-up. However, the effectiveness of oral anticoagulations in reducing the incidence of ischemic stroke in patients with atrial fibrillation lasting less than 24 h, though reasonable, is currently unproven. The future of atrial fibrillation detection tools and atrial fibrillation detection strategies will be influenced by ongoing studies exploring whether oral anticoagulations reduce the incidence of stroke in patients with atrial fibrillation burden lower than 24 h.
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