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Elkind MSV, Wachter R, Verma A, Kowey PR, Halperin JL, Gersh BJ, Ziegler PD, Pouliot E, Franco N, Reiffel JA. Use of the HAVOC Score to Identify Patients at Highest Risk of Developing Atrial Fibrillation. Cardiology 2021; 146:633-640. [PMID: 34157712 DOI: 10.1159/000517827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 06/13/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Mitchell S V Elkind
- Departments of Neurology and Epidemiology, Columbia University, New York, New York, USA
| | - Rolf Wachter
- University Hospital Leipzig, Leipzig, Germany
- University Medicine Göttingen and German Cardiovascular Research Center, Göttingen, Germany
| | - Atul Verma
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | - Peter R Kowey
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
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Maervoet J, Bossers N, Borge RP, Hilpert ST, van Engen A, Smala A. Use of insertable cardiac monitors for the detection of atrial fibrillation in patients with cryptogenic stroke in the United States is cost-effective. J Med Econ 2019; 22:1221-1234. [PMID: 31480905 DOI: 10.1080/13696998.2019.1663355] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objectives: Atrial fibrillation (AF) is the most common arrhythmia and a major marker of ischemic stroke risk. Early detection is crucial and, once diagnosed, anticoagulation therapy can be initiated to reduce stroke risk. The aim of this study was to assess the cost-effectiveness of employing an insertable cardiac monitor (ICM), BIOMONITOR, for the detection of AF compared to standard of care (SoC) ECG and Holter monitoring in patients with cryptogenic stroke, that is, stroke of unknown origin and where paroxysmal, silent AF is suspected. Materials and methods: A Markov model was developed which consisted of five main health states reflecting the potential lifetime evolution of the AF disease: post cryptogenic stroke (index event), subsequent mild, moderate and severe stroke, and death. Sub-states were included to track a patient's AF diagnostic status and the use of antiplatelet or anticoagulant therapy. AF detection was assumed to result in a treatment switch from aspirin to anticoagulants, except among those with a history of major bleeding. Detection yield and accuracy, clinical actions and treatment effects were derived from the literature and validated by an expert clinician. All relevant costs from a US Medicare perspective were included. Results and conclusions: An ICM-based strategy was associated with a reduction of 37 secondary ischemic strokes per 1000 patients monitored compared with SoC. Total per-patient costs with an ICM were higher (US$90,052 vs. US$85,157) although stroke-related costs were reduced. The use of an ICM was associated with a base-case incremental cost-effectiveness ratio of US$18,487 per life year gained compared with SoC and US$25,098 per quality-adjusted life year gained, below established willingness-to-pay thresholds. The conclusions were found to be robust over a range of input values. From a US Medicare perspective the use of a BIOMONITOR ICM represents a cost-effective diagnostic strategy for patients with cryptogenic stroke and suspected AF.
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Affiliation(s)
| | - N Bossers
- Performation Healthcare , Bilthoven , the Netherlands
| | - R P Borge
- Abington Hospital - Jefferson Health , Abington , PA , USA
| | | | | | - A Smala
- BIOTRONIK SE & Co KG , Berlin , Germany
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Reiffel JA, Verma A, Kowey PR, Halperin JL, Gersh BJ, Wachter R, Pouliot E, Ziegler PD. Incidence of Previously Undiagnosed Atrial Fibrillation Using Insertable Cardiac Monitors in a High-Risk Population: The REVEAL AF Study. JAMA Cardiol 2019; 2:1120-1127. [PMID: 28842973 DOI: 10.1001/jamacardio.2017.3180] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance In approximately 20% of atrial fibrillation (AF)-related ischemic strokes, stroke is the first clinical manifestation of AF. Strategies are needed to identify and therapeutically address previously undetected AF. Objective To quantify the incidence of AF in patients at high risk for but without previously known AF using an insertable cardiac monitor. Design, Setting, and Participants This prospective, single-arm, multicenter study was conducted from November 2012 to January 2017. Visits took place at 57 centers in the United States and Europe. Patients with a CHADS2 score of 3 or greater (or 2 with at least 1 additional risk factor) were enrolled. Approximately 90% had nonspecific symptoms potentially compatible with AF, such as fatigue, dyspnea, and/or palpitations. Exposures Patients underwent monitoring with an insertable cardiac monitor for 18 to 30 months. Main Outcomes and Measures The primary end point was adjudicated AF lasting 6 or more minutes and was assessed at 18 months. Other analyses included detection rates at points from 30 days to 30 months and among CHADS2 score subgroups. Median time from insertion to detection and the percentage of patients subsequently prescribed oral anticoagulation therapy was also determined. Results A total of 446 patients were enrolled; 233 (52.2%) were male, and the mean (SD) age was 71.5 (9.9) years. A total of 385 patients (86.3%) received an insertable cardiac monitor, met the primary analysis cohort definition, and were observed for a mean (SD) period of 22.5 (7.7) months. The detection rate of AF lasting 6 or more minutes at 18 months was 29.3%. Detection rates at 30 days and 6, 12, 24, and 30 months were 6.2%, 20.4%, 27.1%, 33.6%, and 40.0%, respectively. At 18 months, AF incidence was similar among patients with CHADS2 scores of 2 (24.7%; 95% CI, 17.3-31.4), 3 (32.7%; 95% CI, 23.8-40.7), and 4 or greater (31.7%; 95% CI, 22.0-40.3) (P = .23). Median (interquartile) time from device insertion to first AF episode detection was 123 (41-330) days. Of patients meeting the primary end point, 13 (10.2%) had 1 or more episodes lasting 24 hours or longer, and oral anticoagulation therapy was prescribed for 72 patients (56.3%). Conclusions and Relevance The incidence of previously undiagnosed AF may be substantial in patients with risk factors for AF and stroke. Atrial fibrillation would have gone undetected in most patients had monitoring been limited to 30 days. Further trials regarding the value of detecting subclinical AF and of prophylactic therapies are warranted. Trial Registration clinicaltrials.gov Identifier: NCT01727297.
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Affiliation(s)
- James A Reiffel
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Peter R Kowey
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | | | | | - Rolf Wachter
- Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
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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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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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