Detection of arrhythmia using an implantable cardiac monitor following a cryptogenic stroke: a single-center observational study

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.

[Medical imaging and headache: choice of studies and their economic impact]

These past few years, new imaging technologies, very efficient but often quite expensive, have been developed. Within the context of budgetary restrictions, these progresses require a carefully planned strategy on the choice of investigations. Within the clinical environment of headaches, we have to discuss: conventional radiology (skill and cervical spine), cerebral CT scan, Magnetic Resonance Imaging and Angiography. These examinations are first discussed about their strong and weak aspects; then their indications are presented by pathology group. The related costs are analysed in terms of: health insurance rate, real production costs, consumption volume and total budgetary cost for Belgium. Based upon these data, concrete recommendations are proposed.