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Gomis M, Dávalos A, Purroy F, Cardona P, Rodríguez-Campello A, Martí-Fábregas J, Pagola J, Pardo L, Muñoz-Narbona L, Benabdelhak I, Lara-Rodríguez B, Cuadrado-Godia E, Martínez-Domeño A, Juega JM, Serena J, Alvarez-Ballano J, Paipa A, Roquer J, Abilleira S, Neeter R, van de Groep A, Molina C. Stroke Risk Analysis, a System With a High Detection Rate of Atrial Fibrillation in Stroke and Transient Ischemic Attack. Stroke 2019; 51:262-267. [PMID: 31842722 DOI: 10.1161/strokeaha.119.026354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Stroke Risk Analysis (SRA) comprises an algorithm for automated analysis of ECG monitoring, enabling the detection of paroxysmal atrial fibrillation (pxAF) and identifying patterns indicating a high risk of atrial fibrillation (R_AF). We compared Holter-enabled continuous ECG monitoring in combination with SRA (hSRA) with standard continuous ECG monitoring for pxAF detection in patients with acute ischemic stroke. Also, we sought to identify whether the detection of R_AF patterns during the first cycle (first 2 hours) of hSRA recording was associated with the detection of pxAF during the Stroke Unit stay. Methods- We enrolled 524 consecutive patients admitted in the Stroke Unit with acute ischemic stroke or transient ischemic attack with neither history of AF nor AF at admission into a prospective multicentric observational analytic clinical study with intrapatient comparison, who received both continuous ECG monitoring as well as hSRA up to 7 days. Investigators were blinded to hSRA results unless pxAF was detected on SRA. Results- Of the 524 consecutive acute stroke patients (median age, 70.0 years; 60% male; acute ischemic stroke 93%, transient ischemic attack 7%), 462 were eligible and included in the study. Among 462 patients with hSRA available for 66 hours, AF was documented by hSRA in 79 patients (17.1%). From this group, 45 AF cases (9.7%) were confirmed after review by an independent and blinded cardiologist. continuous ECG monitoring detected 21 AF cases (4.3%; P<0.0001). hSRA detected R_AF patterns in 92 patients. 35 out of the 92 R_AF patients showed an episode of AF during the Stroke Unit stay. Predictive values of R_AF patterns within the first cycle of hSRA were: sensitivity 71%, specificity 86%, positive predictive value 38%, and negative predictive value 96%. Conclusions- Automated analysis using SRA technology strongly improves pxAF detection in acute ischemic stroke patients compared with continuous ECG monitoring. The predictive value of a R_AF pattern, as detected by hSRA during the first few hours after admission, deserves further investigation.
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Affiliation(s)
- Meritxell Gomis
- From the Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Neurosciences, Badalona-Barcelona, Spain (M.G., A.D., L.M.-N., J.A.-B.)
| | - Antoni Dávalos
- From the Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Neurosciences, Badalona-Barcelona, Spain (M.G., A.D., L.M.-N., J.A.-B.)
| | - Francisco Purroy
- Department of Neurology, Hospital Arnau de Vilanova, Lleida, Spain (F.P., I.B.)
| | - Pere Cardona
- Department of Neurology, Hospital de Bellvitge, Hospitalet de Llobregat-Barcelona, Spain (P.C., B.L.-R., A.P)
| | | | - Joan Martí-Fábregas
- Department of Neurology, Hospital de Sant Pau, Barcelona, Spain (J.M.-F., A.M.-D.)
| | - Jorge Pagola
- Department of Neurology, Hospital Vall d'Hebrón, Barcelona, Spain (J.P., J.M.J., C.M.)
| | - Laura Pardo
- Department of Neurology, Hospital Doctor Josep Trueta, Girona, Spain (L.P., J.S.)
| | - Lucía Muñoz-Narbona
- From the Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Neurosciences, Badalona-Barcelona, Spain (M.G., A.D., L.M.-N., J.A.-B.)
| | - Ikram Benabdelhak
- Department of Neurology, Hospital Arnau de Vilanova, Lleida, Spain (F.P., I.B.)
| | - Blanca Lara-Rodríguez
- Department of Neurology, Hospital de Bellvitge, Hospitalet de Llobregat-Barcelona, Spain (P.C., B.L.-R., A.P)
| | - Elisa Cuadrado-Godia
- Department of Neurology, Hospital de Mar, Barcelona, Spain (A.R.-C., E.C.-G., J.R.)
| | | | - Jesús Maria Juega
- Department of Neurology, Hospital Vall d'Hebrón, Barcelona, Spain (J.P., J.M.J., C.M.)
| | - Joaquin Serena
- Department of Neurology, Hospital Doctor Josep Trueta, Girona, Spain (L.P., J.S.)
| | - Jesús Alvarez-Ballano
- From the Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Neurosciences, Badalona-Barcelona, Spain (M.G., A.D., L.M.-N., J.A.-B.)
| | - Andrés Paipa
- Department of Neurology, Hospital de Bellvitge, Hospitalet de Llobregat-Barcelona, Spain (P.C., B.L.-R., A.P)
| | - Jaume Roquer
- Department of Neurology, Hospital de Mar, Barcelona, Spain (A.R.-C., E.C.-G., J.R.)
| | - Sònia Abilleira
- Stroke Programme, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain (S.A.)
| | - Rob Neeter
- Evina Health Solutions, the Netherlands (R.N., A.v.d.G.)
| | | | - Carlos Molina
- Department of Neurology, Hospital Vall d'Hebrón, Barcelona, Spain (J.P., J.M.J., C.M.)
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2
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Ois A, Cuadrado-Godia E, Giralt-Steinhauer E, Jimenez-Conde J, Soriano-Tarraga C, Rodríguez-Campello A, Avellaneda C, Cascales D, Fernandez-Perez I, Roquer J. Long-Term Stroke Recurrence after Transient Ischemic Attack: Implications of Etiology. J Stroke 2019; 21:184-189. [PMID: 30991798 PMCID: PMC6549066 DOI: 10.5853/jos.2018.03601] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 02/18/2019] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose To analyze long-term stroke recurrence (SR) characteristics after transient ischemic attack (TIA) according to initial etiological classification.
Methods A prospective cohort of 706 TIA patients was followed up in a single tertiary stroke center. Endpoint was SR. Etiologic subgroup was determined according to the evidence-based causative classification system. Location of TIA and SR was recorded as right, left, or posterior territory. Disability stroke recurrence (DSR) was defined as modified Rankin Scale (mRS) score >1 or a onepoint increase in those with previous mRS >1 at 3-month follow-up.
Results During a follow-up of 3,493 patient-years (mean follow-up of 58.9±35.9 months), total SR was 125 (17.7%), corresponding to 3.6 recurrences per 100 patient-years. The etiology subgroups with a higher risk of SR were the unclassified (more than one cause) and large-artery atherosclerosis (LAA) categories. Of the SR cases, 88 (70.4%) had the same etiology as the index TIA; again, LAA etiology was the most frequent (83.9%). Notably, cardioaortic embolism was the most frequent cause (62.5%) of SR in the subgroup of 24 patients with undetermined TIA. Overall, SR occurred in the same territory in 74 of 125 patients (59.2%), with significant differences between etiological TIA subgroups (P=0.015). Eighty-two of 125 (65.6%) with SR had DSR, without differences between etiologies (P=0.453).
Conclusions SR occurred mainly with the same etiology and location as initial TIA, although undetermined TIA was associated with a high proportion of cardioaortic embolism SR. More than half of the recurrences caused some disability, regardless of etiology.
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Affiliation(s)
- Angel Ois
- Department of Neurology, Hospital del Mar, Barcelona, Spain.,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain.,Department of Experimental and Health Sciences, University Pompeu Fabra, Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Department of Neurology, Hospital del Mar, Barcelona, Spain.,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain.,Department of Experimental and Health Sciences, University Pompeu Fabra, Barcelona, Spain
| | - Eva Giralt-Steinhauer
- Department of Neurology, Hospital del Mar, Barcelona, Spain.,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain.,Department of Experimental and Health Sciences, University Pompeu Fabra, Barcelona, Spain
| | - Jordi Jimenez-Conde
- Department of Neurology, Hospital del Mar, Barcelona, Spain.,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain.,Department of Experimental and Health Sciences, University Pompeu Fabra, Barcelona, Spain
| | - Carolina Soriano-Tarraga
- Department of Neurology, Hospital del Mar, Barcelona, Spain.,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain.,Department of Experimental and Health Sciences, University Pompeu Fabra, Barcelona, Spain
| | - Ana Rodríguez-Campello
- Department of Neurology, Hospital del Mar, Barcelona, Spain.,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain.,Department of Experimental and Health Sciences, University Pompeu Fabra, Barcelona, Spain
| | - Carla Avellaneda
- Department of Neurology, Hospital del Mar, Barcelona, Spain.,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain.,Department of Experimental and Health Sciences, University Pompeu Fabra, Barcelona, Spain
| | - Diego Cascales
- Department of Neurology, Hospital del Mar, Barcelona, Spain
| | | | - Jaume Roquer
- Department of Neurology, Hospital del Mar, Barcelona, Spain.,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain.,Autonomous University of Barcelona, Barcelona, Spain.,Department of Experimental and Health Sciences, University Pompeu Fabra, Barcelona, Spain
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3
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Korompoki E, Del Giudice A, Hillmann S, Malzahn U, Gladstone DJ, Heuschmann P, Veltkamp R. Cardiac monitoring for detection of atrial fibrillation after TIA: A systematic review and meta-analysis. Int J Stroke 2016; 12:33-45. [DOI: 10.1177/1747493016669885] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background and purpose The detection rate of atrial fibrillation has not been studied specifically in transient ischemic attack (TIA) patients although extrapolation from ischemic stroke may be inadequate. We conducted a systematic review and meta-analysis to determine the rate of newly diagnosed atrial fibrillation using different methods of ECG monitoring in TIA. Methods A comprehensive literature search was performed following a pre-specified protocol the PRISMA statement. Prospective observational studies and randomized controlled trials were considered that included TIA patients who underwent cardiac monitoring for >12 h. Primary outcome was frequency of detection of atrial fibrillation ≥30 s. Analyses of subgroups and of duration and type of monitoring were performed. Results Seventeen studies enrolling 1163 patients were included. The pooled atrial fibrillation detection rate for all methods was 4% (95% CI: 2–7%). Yield of monitoring was higher in selected (higher age, more extensive testing for arrhythmias before enrolment, or presumed cardioembolic/cryptogenic cause) than in unselected cohorts (7% vs 3%). Pooled mean atrial fibrillation detection rates rose with duration of monitoring: 4% (24 h), 5% (24 h to 7 days) and 6% (>7 days), respectively. Yield of non-invasive was significantly lower than that of invasive monitoring (4% vs. 11%). Significant heterogeneity was observed among studies (I2=60.61%). Conclusion This first meta-analysis of atrial fibrillation detection in TIA patients finds a lower atrial fibrillation detection rate in TIA than reported for IS and TIA cohorts in previous meta-analyses. Prospective studies are needed to determine actual prevalence of atrial fibrillation and optimal diagnostic procedure for atrial fibrillation detection in TIA.
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Affiliation(s)
- Eleni Korompoki
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - Angela Del Giudice
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - Steffi Hillmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Uwe Malzahn
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Clinical Trial Center, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - David J Gladstone
- Division of Neurology, Department of Medicine, University Toronto, Ontario, Canada
| | - Peter Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
- Clinical Trial Center, Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
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4
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Demeestere J, Fieuws S, Lansberg MG, Lemmens R. Detection of Atrial Fibrillation Among Patients With Stroke Due to Large or Small Vessel Disease: A Meta-Analysis. J Am Heart Assoc 2016; 5:e004151. [PMID: 27671319 PMCID: PMC5079054 DOI: 10.1161/jaha.116.004151] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/01/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recent trials have demonstrated that extended cardiac monitoring increases the yield of paroxysmal atrial fibrillation (AF) detection in patients with cryptogenic stroke. The utility of extended cardiac monitoring is uncertain among patients with stroke caused by small and large vessel disease. We conducted a meta-analysis to estimate the yield of AF detection in this population. METHODS AND RESULTS We searched PubMed, Cochrane, and SCOPUS databases for studies on AF detection in stroke patients and excluded studies restricted to patients with cryptogenic stroke or transient ischemic attack. We abstracted AF detection rates for 3 populations grouped by stroke etiology: large vessel stroke, small vessel stroke, and stroke of undefined etiology (a mixture of cryptogenic, small vessel, large vessel, and other stroke etiologies). Our search yielded 30 studies (n=5687). AF detection rates were similar in patients with large vessel (2.2%, 95% CI 0.3-5.5; n=830) and small vessel stroke (2.4%, 95% CI 0.4-6.1; n=520). No studies had a monitoring duration longer than 7 days. The yield of AF detection in the undefined stroke population was higher (9.2%; 95% CI 7.1-11.5) compared to small vessel stroke (P=0.02) and large vessel stroke (P=0.02) populations. CONCLUSIONS AF detection rate is similar in patients with small and large vessel strokes (2.2-2.4%). Because no studies reported on extended monitoring (>7 days) in these stroke populations, we could not estimate the yield of AF detection with long-term cardiac monitoring. Randomized controlled trials are needed to examine the utility of AF detection with long-term cardiac monitoring (>7 days) in this patient population.
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Affiliation(s)
- Jelle Demeestere
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Interuniversitary Institute for Biostatistics and Statistical Bio-information, KU Leuven-University of Leuven & Universiteit Hasselt, Leuven, Belgium
| | | | - Robin Lemmens
- KU Leuven-University of Leuven, Department of Neurosciences Experimental Neurology and Leuven Research Institute for Neuroscience and Disease (LIND), Leuven, Belgium VIB, Vesalius Research Center Laboratory of Neurobiology, Leuven, Belgium University Hospitals Leuven, Department of Neurology, Leuven, Belgium
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5
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Montalvo M, Ali R, Silver B, Khan M. Long-term Arrhythmia Monitoring in Cryptogenic Stroke: Who, How, and for How Long? Open Cardiovasc Med J 2016; 10:89-93. [PMID: 27347225 PMCID: PMC4897003 DOI: 10.2174/1874192401610010089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 10/08/2015] [Accepted: 11/25/2015] [Indexed: 11/22/2022] Open
Abstract
Cryptogenic stroke and transient ischemic attack (TIA) account for approximately one-third of stroke patients [1]. Paroxys-mal atrial fibrillation (PAF) has been suggested as a major etiology of these cryptogenic strokes [2, 3]. PAF can be difficult to diagnose because it is intermittent, often brief, and asymptomatic. PAF might be more prevalent than persistent atrial fibrillation in stroke and TIA patients, especially in younger populations [4, 5]. In patients with atrial fibrillation, anticoagulation provides significant risk reduction [6]. A new generation of oral anticoagulants has been approved for non-valvular atrial fibrillation, providing a variety of therapeutic options for patients with atrial fibrillation and risk of stroke [7]. Prior practice included an admission electrocardiogram (ECG) and continuous telemetry monitoring while in hospital [8]. However, this approach can lead to under-detection of brief asymptomatic events, which can occur at variable intervals, often outside of the hospital setting. Technological advancements have led to devices that can monitor cardiac rhythms outside of the hospital for longer durations resulting in higher yield of detection of atrial fibrillation events. Moreover, recent studies show that the normal monitoring time for arrhythmias may be shorter than ideal in order to detect atrial fibrillation, and increasing this interval could significantly improve detection of atrial fibrillation in these patients [9, 10]. The aim of this study is to review the literature in order to define what subgroup of patients, with what methodologies, and for how long monitoring for atrial fibrillation should occur in patients presenting with cryptogenic stroke.
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Affiliation(s)
- Mayra Montalvo
- Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, 96/79 13 Street, Boston, MA 02129, USA
| | - Rushna Ali
- Department of Neurosurgery, Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI 48202, USA
| | - Brian Silver
- Department of Neurology, Warren Alpert Medical School, Brown University, 110 Lockwood Street, Suite 324, Prov-idence, RI 02903, USA
| | - Muhib Khan
- Department of Neurology, Warren Alpert Medical School, Brown University, 110 Lockwood Street, Suite 324, Prov-idence, RI 02903, USA
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6
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Optimal Duration of Monitoring for Atrial Fibrillation in Cryptogenic Stroke: A Nonsystematic Review. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5704963. [PMID: 27314027 PMCID: PMC4903126 DOI: 10.1155/2016/5704963] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/21/2016] [Accepted: 05/03/2016] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) is the most common form of cardiac arrhythmias and an independent risk factor for stroke. Despite major advances in monitoring strategies, clinicians tend to miss the diagnoses of AF and especially paroxysmal AF due mainly to its asymptomatic presentation and the rather limited duration dedicated for monitoring for AF after a stroke, which is 24 hours as per the current recommended guidelines. Hence, determining the optimal duration of monitoring for paroxysmal atrial fibrillation after acute ischemic stroke remains a matter of debate. Multiple trials were published in regard to this matter using both invasive and noninvasive monitoring strategies for different monitoring periods. The data provided by these trials showcase strong evidence suggesting a longer monitoring strategy beyond 24 hours is associated with higher detection rates of AF, with the higher percentage of patients detected consequently receiving proper secondary stroke prevention with anticoagulation and thus justifying the cost-effectiveness of such measures. Overall, we thus conclude that increasing the monitoring duration for AF after a cryptogenic stroke to at least 72 hours will indeed enhance the detection rates, but the cost-effectiveness of this monitoring strategy compared to longer monitoring durations is yet to be established.
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7
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Andrade JG, Field T, Khairy P. Detection of occult atrial fibrillation in patients with embolic stroke of uncertain source: a work in progress. Front Physiol 2015; 6:100. [PMID: 25883570 PMCID: PMC4381503 DOI: 10.3389/fphys.2015.00100] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/12/2015] [Indexed: 02/02/2023] Open
Abstract
Atrial fibrillation accounts for a substantial proportion of ischemic strokes of known etiology and may be responsible for an additional subset of the 25–40% of strokes of unknown cause (so-called cryptogenic). Oral anticoagulation is significantly more effective than antiplatelet therapy in the secondary prevention of atrial fibrillation-related strokes, providing justification for developing more sensitive approaches to detecting occult paroxysms of atrial fibrillation. In this article, we summarize the current state of knowledge regarding the value of in-hospital and out-patient monitoring for detecting atrial fibrillation in the context of cryptogenic stroke. We review the evidence for and against screening with standard Holter monitors, external loop recorders, the newer real-time continuous attended cardiac monitoring systems, cardiac implantable electronic devices, and insertable loop recorders. We review key questions regarding prolonged cardiac arrhythmia monitoring, including the relationship between duration of the atrial fibrillation episode and risk of thromboembolism, frequency of monitoring and its impact on the diagnostic yield in detecting occult or subclinical atrial fibrillation, and the temporal proximity of device-detected atrial fibrillation to stroke events. We conclude by proposing avenues for further research.
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Affiliation(s)
- Jason G Andrade
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal Montreal, QC, Canada ; Department of Medicine, Division of Cardiology, University of British Columbia Vancouver, BC, Canada
| | - Thalia Field
- Department of Medicine, Division of Neurology, University of British Columbia Vancouver, BC, Canada
| | - Paul Khairy
- Electrophysiology Service, Department of Medicine, Montreal Heart Institute, Université de Montréal Montreal, QC, Canada
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8
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Sposato LA, Cipriano LE, Saposnik G, Vargas ER, Riccio PM, Hachinski V. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2015; 14:377-87. [DOI: 10.1016/s1474-4422(15)70027-x] [Citation(s) in RCA: 387] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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9
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Kishore A, Vail A, Majid A, Dawson J, Lees KR, Tyrrell PJ, Smith CJ. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke 2014; 45:520-6. [PMID: 24385275 DOI: 10.1161/strokeaha.113.003433] [Citation(s) in RCA: 257] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Atrial fibrillation (AF) confers a high risk of recurrent stroke, although detection methods and definitions of paroxysmal AF during screening vary. We therefore undertook a systematic review and meta-analysis to determine the frequency of newly detected AF using noninvasive or invasive cardiac monitoring after ischemic stroke or transient ischemic attack. METHODS Prospective observational studies or randomized controlled trials of patients with ischemic stroke, transient ischemic attack, or both, who underwent any cardiac monitoring for a minimum of 12 hours, were included after electronic searches of multiple databases. The primary outcome was detection of any new AF during the monitoring period. We prespecified subgroup analysis of selected (prescreened or cryptogenic) versus unselected patients and according to duration of monitoring. RESULTS A total of 32 studies were analyzed. The overall detection rate of any AF was 11.5% (95% confidence interval, 8.9%-14.3%), although the timing, duration, method of monitoring, and reporting of diagnostic criteria used for paroxysmal AF varied. Detection rates were higher in selected (13.4%; 95% confidence interval, 9.0%-18.4%) than in unselected patients (6.2%; 95% confidence interval, 4.4%-8.3%). There was substantial heterogeneity even within specified subgroups. CONCLUSIONS Detection of AF was highly variable, and the review was limited by small sample sizes and marked heterogeneity. Further studies are required to inform patient selection, optimal timing, methods, and duration of monitoring for detection of AF/paroxysmal AF.
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Affiliation(s)
- Amit Kishore
- From the Stroke and Vascular Research Centre, Institute of Cardiovascular Sciences (A.K., P.J.T., C.J.S.) and Centre for Biostatistics (A.V.), University of Manchester, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford, United Kingdom; Greater Manchester Comprehensive Stroke Centre, Department of Medical Neurosciences, Salford Royal Foundation Trust, Salford, United Kingdom (A.K., A.M., P.J.T., C.J.S.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Western Infirmary, Glasgow, United Kingdom (J.D., K.R.L.)
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10
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Suissa L, Lachaud S, Mahagne MH. Optimal Timing and Duration of Continuous Electrocardiographic Monitoring for Detecting Atrial Fibrillation in Stroke Patients. J Stroke Cerebrovasc Dis 2013; 22:991-5. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.01.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 11/30/2022] Open
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Rizos T, Güntner J, Jenetzky E, Marquardt L, Reichardt C, Becker R, Reinhardt R, Hepp T, Kirchhof P, Aleynichenko E, Ringleb P, Hacke W, Veltkamp R. Continuous Stroke Unit Electrocardiographic Monitoring Versus 24-Hour Holter Electrocardiography for Detection of Paroxysmal Atrial Fibrillation After Stroke. Stroke 2012; 43:2689-94. [DOI: 10.1161/strokeaha.112.654954] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Timolaos Rizos
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Janina Güntner
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Ekkehart Jenetzky
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Lars Marquardt
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Christine Reichardt
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Rüdiger Becker
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Roland Reinhardt
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Thomas Hepp
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Paulus Kirchhof
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Elena Aleynichenko
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Peter Ringleb
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Werner Hacke
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
| | - Roland Veltkamp
- From the Departments of Neurology, (T.R., J.G., L.M., C.R., P.R., W.H., R.V.) and Cardiology (R.B.), University of Heidelberg, Heidelberg, Germany; the Department of Clinical Epidemiology and Aging Research (C070), German Cancer Research Center (DKFZ), Heidelberg, Germany (E.J.); the Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany (L.M.); Apoplex Medical Technologies GmbH, Pirmasens, Germany (R.R., T.H.); the University of Birmingham Cardiovascular Sciences Center,
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12
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Abstract
Stroke and atrial fibrillation (AF) constitute a true vascular epidemic with catastrophic consequences. The most common and devastating complication of AF is cardioembolic stroke but this catastrophic event can be predicted and prevented. Accurate etiologic diagnosis of stroke is essential for effective prevention. The percentage of cryptogenic ischemic strokes is too high and detection of AF and other causes of cardioembolic events should be improved. Cardioembolic cerebral ischemia can be prevented. However, because of physician inertia, lack of patient adherence and the problems of vitamin K antagonists, many patients are at risk of cerebral ischemia. Recently, major advances with drugs such as dronedarone, dabigatran and FXa inhibitors have opened the way to improving stroke prevention, as reflected in therapeutic guidelines, and neurologists should be familiar with these drugs. There is reason to hope that much suffering can be avoided.
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Affiliation(s)
- Antonio Gil Núñez
- Unidad de Ictus, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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13
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Kallmünzer B, Breuer L, Hering C, Raaz-Schrauder D, Kollmar R, Huttner HB, Schwab S, Köhrmann M. A Structured Reading Algorithm Improves Telemetric Detection of Atrial Fibrillation After Acute Ischemic Stroke. Stroke 2012; 43:994-9. [DOI: 10.1161/strokeaha.111.642199] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bernd Kallmünzer
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Lorenz Breuer
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Christiane Hering
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Dorette Raaz-Schrauder
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Rainer Kollmar
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Hagen B. Huttner
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Stefan Schwab
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
| | - Martin Köhrmann
- From the Departments of Neurology (B.K., L.B., C.H., R.K., H.B.H., S.S., M.K.) and Cardiology (D.R.-S.), University Medical Center Erlangen, Erlangen, Germany
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14
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Seet RC, Friedman PA, Rabinstein AA. Prolonged Rhythm Monitoring for the Detection of Occult Paroxysmal Atrial Fibrillation in Ischemic Stroke of Unknown Cause. Circulation 2011; 124:477-86. [PMID: 21788600 DOI: 10.1161/circulationaha.111.029801] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Raymond C.S. Seet
- From the Departments of Neurology (R.C.S.S., A.A.R.) and Cardiology (P.A.F.), Mayo Clinic, Rochester, MN; and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (R.C.S.S.)
| | - Paul A. Friedman
- From the Departments of Neurology (R.C.S.S., A.A.R.) and Cardiology (P.A.F.), Mayo Clinic, Rochester, MN; and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (R.C.S.S.)
| | - Alejandro A. Rabinstein
- From the Departments of Neurology (R.C.S.S., A.A.R.) and Cardiology (P.A.F.), Mayo Clinic, Rochester, MN; and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (R.C.S.S.)
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