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Andrade JG, Moss JWE, Kuniss M, Sadri H, Wazni O, Sale A, Ismyrloglou E, Chierchia GB, Kaplon R, Mealing S, Bainbridge J, Bromilow T, Lane E, Khaykin Y. The Cost-Effectiveness of First-Line Cryoablation vs First-Line Antiarrhythmic Drugs in Canadian Patients With Paroxysmal Atrial Fibrillation. Can J Cardiol 2024; 40:576-584. [PMID: 38007219 DOI: 10.1016/j.cjca.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/24/2023] [Accepted: 11/20/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND The EARLY-AF (NCT02825979), STOP AF First (NCT03118518), and Cryo-FIRST (NCT01803438) randomised controlled trials (RCTs) demonstrated that cryoballoon pulmonary vein isolation reduces atrial fibrillation (AF) recurrence compared with antiarrhythmic drugs (AADs) in patients with symptomatic paroxysmal atrial fibrillation (PAF). The present study developed a cost-effectiveness model (CEM) of first-line cryoablation compared with first-line AADs for PAF, from the Canadian health care payer's perspective. METHODS Data from the 3 RCTs were analysed to estimate key CEM parameters. The model structure used a decision tree for the first 12 months and a Markov model with a 3-month cycle length for the remaining lifetime time horizon. Costs were set at 2023 Canadian dollars, health benefits were expressed as quality-adjusted life years (QALYs), and both were discounted 3% annually. Probabilistic sensitivity analysis (PSA) considered parameter uncertainty. RESULTS The statistical analysis estimated that first-line cryoablation generates a 47% reduction (P < 0.001) in the rate of AF recurrence, a 73% reduction in the rate of subsequent ablation (P < 0.001), and a 4.3% (P = 0.025) increase in health-related quality of life, compared with first-line AADs. The PSA indicates that an individual treated with first-line cryoablation accrues less costs (-$3,862) and more QALYs (0.19) compared with first-line AADs. Cryoablation is cost-saving in 98.4% of PSA iterations and has a 99.9% probability of being cost-effective at a cost-effectiveness threshold of $50,000 per QALY gained. Cost-effectiveness results were robust to changes in key model parameters. CONCLUSIONS First-line cryoballoon ablation is cost-effective when compared with AADs for patients with symptomatic PAF.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Joe W E Moss
- York Health Economics Consortium, York, United Kingdom
| | - Malte Kuniss
- Kerckhoff Clinic Heart Centrum, Department of Cardiology, Bad Nauheim, Germany
| | | | | | | | | | | | | | | | | | - Tom Bromilow
- York Health Economics Consortium, York, United Kingdom
| | - Emily Lane
- York Health Economics Consortium, York, United Kingdom
| | - Yaariv Khaykin
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
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2
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Apple SJ, Flomenbaum D, Parker M, Chhikara S, Stolarov A, Moser J, Mathai SV, Seo J, Ferrick N, Chudow JJ, Di Biase L, Krumerman A, Ferrick KJ. Low Utility of Short-Term Rhythm Assessment Before Long-Term Rhythm Monitoring in Patients With Cryptogenic Stroke. Am J Cardiol 2023; 202:151-159. [PMID: 37437356 DOI: 10.1016/j.amjcard.2023.06.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/01/2023] [Accepted: 06/11/2023] [Indexed: 07/14/2023]
Abstract
Implantable cardiac monitors are routinely placed for long-term monitoring (LTM) after a period of negative short-term monitoring (STM) to increase atrial fibrillation (AF) detection after a cryptogenic stroke or transient ischemic attack (TIA). Optimizing AF monitoring after a cryptogenic stroke is critical to improve outcomes and reduce costs. We sought to compare the diagnostic yield of STM versus LTM, assess the impact of routine STM on hospitalization length of stay, and perform a financial analysis comparing the current model to a theoretical model wherein patients can proceed directly to LTM. Our retrospective observational cohort study analyzed patients admitted to Montefiore Medical Center between May 2017 and June 2022 with a primary diagnosis of cryptogenic stroke or TIA who underwent Holter device monitoring. Of 396 subjects, STM detected AF in 10 (2.5%) compared with a diagnostic yield of 14.6% for LTM (median time to diagnosis of 76 days). Of the 386 patients with negative STM, 130 (33.7%) received an implantable cardiac monitor while an inpatient, and 256 (66.3%) did not. We calculated a point estimate of 1.67 days delay of discharge attributable to the requirement for STM to precede LTM. Our model showed that the expected cost per patient in the STM-first paradigm is $28,615.33 versus $27,111.24 in the LTM-or-STM paradigm. Considering the relatively lower diagnostic yield of STM and its association with a longer length of stay and higher costs, it may be reasonable to proceed directly to LTM to optimize AF detection after a cryptogenic stroke or TIA.
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Affiliation(s)
- Samuel J Apple
- Department of Medicine, New York City Health and Hospitals/Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | - David Flomenbaum
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Matthew Parker
- Department of Medicine, New York City Health and Hospitals/Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sanya Chhikara
- Department of Medicine, New York City Health and Hospitals/Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Aaron Stolarov
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Jack Moser
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Sheetal Vasundara Mathai
- Department of Medicine, New York City Health and Hospitals/Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Jiyoung Seo
- Department of Medicine, New York City Health and Hospitals/Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Neal Ferrick
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Bronx, New York
| | - Jay J Chudow
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Bronx, New York
| | - Luigi Di Biase
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Bronx, New York
| | - Andrew Krumerman
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Bronx, New York
| | - Kevin J Ferrick
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Bronx, New York
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Wazni O, Moss J, Kuniss M, Andrade J, Chierchia GB, Mealing S, Mburu W, Sale A, Kaplon R, Ismyrloglou E, Bromilow T, Lane E, Lewis D, Reynolds MR. An economic evaluation of first-line cryoballoon ablation vs antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from a U.S. Medicare perspective. Heart Rhythm O2 2023; 4:528-537. [PMID: 37744940 PMCID: PMC10513914 DOI: 10.1016/j.hroo.2023.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background Three recent randomized controlled trials have demonstrated that, as an initial rhythm control strategy, first-line cryoballoon ablation (cryoablation) reduces atrial arrhythmia recurrence compared with antiarrhythmic drugs (AADs) in patients with symptomatic paroxysmal atrial fibrillation (PAF). Objective The study sought to evaluate the cost-effectiveness of first-line cryoablation compared with first-line AADs for treating symptomatic PAF from a U.S. Medicare payer perspective. Methods Individual patient-level data from 703 participants with PAF enrolled into the Cryo-FIRST (NCT01803438), STOP AF First (NCT03118518), and EARLY-AF (NCT02825979) trials were used to derive parameters for the cost-effectiveness model. The cost-effectiveness model used a hybrid decision tree and Markov structure. The decision tree had a 1-year time horizon and was used to inform the initial health state allocation in the first cycle of the Markov model. The Markov model used a 40-year time horizon (3-month cycle length). Health benefits were expressed in quality-adjusted life years (QALYs). Costs and benefits were discounted at 3% per year. Results Cryoablation was estimated to yield higher QALYs (+0.17) and higher costs (+$4274) per patient over a 40-year time horizon than AADs. Ultimately, this produced an average incremental cost-effectiveness ratio of $24,637 per QALY gained. Independent of initial treatment, individuals were expected to receive ∼1.2 ablations over a lifetime. There was a 45% relative reduction in time spent in atrial fibrillation health states for those initially treated with cryoablation compared with AADs. Conclusion Initial rhythm control with first-line cryoballoon ablation is highly cost-effective compared with first-line AADs from a U.S. Medicare payer perspective.
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Affiliation(s)
- Oussama Wazni
- Department of Cardiac Electrophysiology and Pacing, Cleveland Clinic, Cleveland, Ohio
| | - Joe Moss
- York Health Economics Consortium, York, United Kingdom
| | - Malte Kuniss
- Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Jason Andrade
- Division of Cardiology and Cardiac Electrophysiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gian Battista Chierchia
- Department of Cardiology at Heart Rhythm Management Center, Universitair Ziekenhuis Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | | | | | - Tom Bromilow
- York Health Economics Consortium, York, United Kingdom
| | - Emily Lane
- York Health Economics Consortium, York, United Kingdom
| | - Damian Lewis
- York Health Economics Consortium, York, United Kingdom
| | - Matthew R. Reynolds
- Baim Institute for Clinical Research, Boston, Massachusetts
- Lahey Hospital and Medical Center, Burlington, Massachusetts
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4
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Piot O, Guidoux C. Searching for atrial fibrillation post stroke: is it time for digital devices? Front Cardiovasc Med 2023; 10:1212128. [PMID: 37576103 PMCID: PMC10412929 DOI: 10.3389/fcvm.2023.1212128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
The detection of atrial fibrillation (AF) in patients with cryptogenic stroke (CS) is an essential part of management to limit the risk of recurrence. However, in practice, not all patients who need AF screening are screened, or are screened with significant delays. The disparities of access to examinations, their costs as well as the increasing workload require an evolution of practices both in terms of organization and the type of equipment used. The ubiquity and ease of use of digital devices, together with their evaluation in large population and their expected lower cost, make them attractive as potential alternatives to current equipment at all stages of patient management. However, reliability and accuracy of each digital device for the detection of paroxysmal AF in CS patients should be established before consideration for inclusion in clinical practice. The aim of this short analysis is therefore to review the current practical issues for AF detection in post stroke patients, the potential benefits and issues using digital devices in stroke patients and to position the different digital devices as alternative to standard equipment at each stage of stroke patient pathway. This may help to design future studies for the evaluation of these devices in this context. Under this condition, the time for digital devices to detect AF after stroke seems very close.
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Affiliation(s)
- Olivier Piot
- Department of Cardiac Arrhythmia, Centre Cardiologique du Nord, Saint-Denis, France
| | - Céline Guidoux
- Department of Neurology and Stroke Unit, Bichat Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
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Wang L, Chen Y, Shen W, Fan X, Jia M, Fu G, Chi X, Liang X, Zhang Y. A Bibliometric Analysis of Cardioembolic Stroke From 2012 to 2022. Curr Probl Cardiol 2023; 48:101537. [PMID: 36529228 DOI: 10.1016/j.cpcardiol.2022.101537] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Cardioembolic stroke, a subtype of ischemic stroke with the worst prognosis, is quietly threatening public health. We aimed to visualize the development trend and hotspots of research on cardioembolic stroke. A total of 2886 papers about cardioembolic stroke published from 2012 to 2022 were retrieved in the Web of Science Core Collection (WoSCC) database. Further, we performed a bibliometric analysis of these publications, such as generating cooperation maps, co-citation analysis of journals and references, and cluster analysis of keywords. According to the results, cardioembolic stroke research faces many clinical challenges. We obtained the knowledge maps of countries/institutions, authors, journals with high publications and citations, and representative references in this field. Studies about optimal prevention strategies for cardioembolic stroke, identification of cardioembolism in cryptogenic stroke, and prophylactic anticoagulation for patients with embolic stroke of undetermined source (ESUS) or at high risk of left ventricle (LV) thrombus are in the spotlight.
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Affiliation(s)
- Liuding Wang
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yifan Chen
- Graduate School, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wei Shen
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xueming Fan
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Min Jia
- Medical Ethics Committee, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Guojing Fu
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiansu Chi
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiao Liang
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Yunling Zhang
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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6
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Chalfoun N, Pierobon J, Rosemas SC, Fox J, Albano A, Banno J, Brunner M, Corner K, Dahu M, Dandamudi S, Davis AT, Elmouchi D, Jawad W, Khan M, Min J, Rai V, Rosema S, Sagorski R, Gauri A. A cost comparison of atrial fibrillation monitoring strategies after embolic stroke of undetermined source. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 21:100195. [PMID: 38559748 PMCID: PMC10978394 DOI: 10.1016/j.ahjo.2022.100195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/11/2022] [Accepted: 08/20/2022] [Indexed: 04/04/2024]
Abstract
Background Detection of atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS) is challenging due to its paroxysmal nature. We sought to assess AF detection with an insertable cardiac monitor (ICM) and to perform cost analysis for various AF monitoring strategies post-ESUS We applied this cost analysis modeling to recently published Stroke AF and Per Diem trials. Methods Retrospective chart review was performed in consecutive hospitalized patients with ESUS who had ICM placed prior to discharge. Utilizing rate of ICM-detected AF and Medicare average payments, we modeled 30-day per-patient diagnostic costs of Immediate ICM insertion prior to discharge versus using a wearable monitor followed by ICM in patients with ESUS, from Medicare and patient out-of-pocket perspectives. Similar modeling strategy and cost analysis was applied to the Stroke AF and Per Diem trials. Results In 192 ESUS patients, AF detection increased with length of monitoring: 7.3 % at 14 days, 9.4 % at 30 days, and 17.2 % after a median ~ 6 months (189 days). Cost modeling predicted that immediate ICM leads to $3683-$4070 lower Medicare payments per-patient and $1425-$1503 lower patient out-of-pocket costs compared to Wearable-to-ICM strategies. Using similar modeling in the PER DIEM and STROKE AF trials, the additive costs of the 30-day ELR to ICM strategy ranged from $3786-$3946 from a payer perspective and $1472-$1503 from a patient out-of-pocket perspective. Conclusions Use of ICM immediately after ESUS is cost-saving compared to Wearable-to-ICM strategies, due to the cost and low diagnostic yield of short-term wearable cardiac monitoring.
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Affiliation(s)
- Nagib Chalfoun
- Division of Cardiology, Spectrum Health, United States of America
- Department of Medicine, Michigan State University, United States of America
| | - Jessica Pierobon
- Division of Cardiology, Spectrum Health, United States of America
| | | | - John Fox
- Medical Affairs, Priority Health, United States of America
| | - Alfred Albano
- Division of Cardiology, Spectrum Health, United States of America
| | - Joseph Banno
- Division of Cardiology, Spectrum Health, United States of America
| | - Michael Brunner
- Division of Cardiology, Spectrum Health, United States of America
| | - Kristin Corner
- Division of Cardiology, Spectrum Health, United States of America
| | - Musa Dahu
- Division of Cardiology, Spectrum Health, United States of America
| | - Sanjay Dandamudi
- Division of Cardiology, Spectrum Health, United States of America
| | - Alan T. Davis
- Division of Cardiology, Spectrum Health, United States of America
| | - Darryl Elmouchi
- Division of Cardiology, Spectrum Health, United States of America
| | - Wassim Jawad
- Division of Cardiology, Spectrum Health, United States of America
| | - Muhib Khan
- Department of Neurology, Spectrum Health, United States of America
| | - Jiangyong Min
- Department of Neurology, Spectrum Health, United States of America
| | - Vivek Rai
- Department of Neurology, Spectrum Health, United States of America
| | - Shelly Rosema
- Division of Cardiology, Spectrum Health, United States of America
| | - Ryan Sagorski
- Division of Cardiology, Spectrum Health, United States of America
| | - Andre Gauri
- Division of Cardiology, Spectrum Health, United States of America
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7
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Dilaveris PE, Antoniou CK, Caiani EG, Casado-Arroyo R, Climent AΜ, Cluitmans M, Cowie MR, Doehner W, Guerra F, Jensen MT, Kalarus Z, Locati ET, Platonov P, Simova I, Schnabel RB, Schuuring M, Tsivgoulis G, Lumens J. ESC Working Group on e-Cardiology Position Paper: accuracy and reliability of electrocardiogram monitoring in the detection of atrial fibrillation in cryptogenic stroke patients : In collaboration with the Council on Stroke, the European Heart Rhythm Association, and the Digital Health Committee. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022; 3:341-358. [PMID: 36712155 PMCID: PMC9707962 DOI: 10.1093/ehjdh/ztac026] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The role of subclinical atrial fibrillation as a cause of cryptogenic stroke is unambiguously established. Long-term electrocardiogram (ECG) monitoring remains the sole method for determining its presence following a negative initial workup. This position paper of the European Society of Cardiology Working Group on e-Cardiology first presents the definition, epidemiology, and clinical impact of cryptogenic ischaemic stroke, as well as its aetiopathogenic association with occult atrial fibrillation. Then, classification methods for ischaemic stroke will be discussed, along with their value in providing meaningful guidance for further diagnostic efforts, given disappointing findings of studies based on the embolic stroke of unknown significance construct. Patient selection criteria for long-term ECG monitoring, crucial for determining pre-test probability of subclinical atrial fibrillation, will also be discussed. Subsequently, the two major classes of long-term ECG monitoring tools (non-invasive and invasive) will be presented, with a discussion of each method's pitfalls and related algorithms to improve diagnostic yield and accuracy. Although novel mobile health (mHealth) devices, including smartphones and smartwatches, have dramatically increased atrial fibrillation detection post ischaemic stroke, the latest evidence appears to favour implantable cardiac monitors as the modality of choice; however, the answer to whether they should constitute the initial diagnostic choice for all cryptogenic stroke patients remains elusive. Finally, institutional and organizational issues, such as reimbursement, responsibility for patient management, data ownership, and handling will be briefly touched upon, despite the fact that guidance remains scarce and widespread clinical application and experience are the most likely sources for definite answers.
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Affiliation(s)
| | - Christos Konstantinos Antoniou
- First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 114 Vas. Sofias Avenue, 11527 Athens, Greece,Electrophysiology and Pacing Laboratory, Athens Heart Centre, Athens Medical Center, Marousi, Attica, Greece
| | - Enrico G Caiani
- Politecnico di Milano, Department of Electronics, Information and Biomedical Engineering, Milan, Italy,National Council of Research, Institute of Electronics, Information and Telecommunication Engineering, Milan, Italy
| | - Ruben Casado-Arroyo
- Department of Cardiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andreu Μ Climent
- ITACA Institute, Universitat Politècnica de València, Camino de Vera s/n, Valencia, Spain
| | - Matthijs Cluitmans
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martin R Cowie
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Wolfram Doehner
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117 Berlin, Germany,Department of Cardiology (Virchow Klinikum), and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital ‘Ospedali Riuniti Umberto I—Lancisi—Salesi’, Ancona, Italy
| | - Magnus T Jensen
- Department of Cardiology, Copenhagen University Hospital Amager & Hvidovre, Denmark
| | - Zbigniew Kalarus
- DMS in Zabrze, Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Emanuela Teresa Locati
- Arrhythmology & Electrophysiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Pyotr Platonov
- Department of Cardiology, Clinical Sciences, Lund University Hospital, Lund, Sweden
| | - Iana Simova
- Cardiology Clinic, Heart and Brain Centre of Excellence—University Hospital, Medical University Pleven, Pleven, Bulgaria
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg-Eppendorf, Hamburg, Germany,German Center for Cardiovascular Research (DZHK) partner site, Hamburg/Kiel/Lübeck, Germany
| | - Mark Schuuring
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Georgios Tsivgoulis
- Second Department of Neurology, ‘Attikon’ University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
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8
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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: 36] [Impact Index Per Article: 18.0] [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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9
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Thiyagarajah A, Cheong E, Lau DH. Implantable Cardiac Monitors in Cryptogenic Stoke – Clarity or Added Uncertainty? Heart Rhythm O2 2022; 3:231-232. [PMID: 35734299 PMCID: PMC9207727 DOI: 10.1016/j.hroo.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Anand Thiyagarajah
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
- Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide, Australia
| | - Edmund Cheong
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
- Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide, Australia
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10
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Yaghi S, Ryan MP, Gunnarsson CL, Irish W, Rosemas SC, Neisen K, Ziegler PD, Reynolds M. Longitudinal Outcomes in Cryptogenic Stroke Patients With and Without Long-term Cardiac Monitoring for Atrial Fibrillation. Heart Rhythm O2 2022; 3:223-230. [PMID: 35734289 PMCID: PMC9207734 DOI: 10.1016/j.hroo.2022.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Guidelines recommend a confirmed diagnosis of atrial fibrillation (AF) to initiate oral anticoagulation in cryptogenic stroke (CS) patients. However, the intermittent nature of AF can make detection challenging with intermittent short-term cardiac monitoring. Objective The purpose of this retrospective cohort study was to examine post-CS utilization of cardiac monitoring and associated clinical outcomes. Methods Adults with incident hospitalization for CS were identified in the Optum® claims database and assessed for cardiac monitoring received poststroke. Patient were stratified into those with a long-term insertable cardiac monitor (ICM) vs external cardiac monitor (ECM) only. The timing of ICM placement poststroke was treated as a time-dependent covariate. The clinical outcomes of interest were time to AF diagnosis, oral anticoagulation usage, and all-cause mortality. Results A total of 12,994 patients met selection criteria for the analysis, of whom 1949 (15%) received an ICM and 11,045 (85%) received ECM only. In those who had received an ECM as their first monitoring modality, only 4.4% moved on to receive an ICM for longer-term monitoring. Use of ECM before ICM was associated with a longer time to AF diagnosis (median 336 vs 194 days). Compared to those with ECM only, ICM patients had a significantly lower rate of death (hazard ratio [HR] 0.70; P = .004), and faster time to AF diagnosis (HR 1.50; P <.0001) and anticoagulation initiation (HR 1.57; P <.0001) during follow-up of up to 5 years after CS. Conclusion In a real-world study of CS patients, prolonged cardiac monitoring was associated with higher rates of AF detection and treatment, and higher odds of survival.
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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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Dormer L. Celebrating 10 years of the Journal of Comparative Effectiveness Research. J Comp Eff Res 2021; 11:1-5. [PMID: 34872331 DOI: 10.2217/cer-2021-0249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Laura Dormer
- Future Medicine Ltd, Unitec House, London, N3 1QB, UK
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