Detection of Atrial Fibrillation After Ischemic Stroke or Transient Ischemic Attack

Abstract

C ardioembolism accounts for 17% to 30% of all ischemic strokes.1,2 Some data suggest that >50% of these are because of atrial fibrillation (AF).3 Paroxysmal AF (PAF) is often undetected because characteristics such as short duration, episodic, and frequently asymptomatic nature make it challenging to diagnose at the bedside, leading to suboptimal secondary prevention. 4 It is likely that a proportion of strokes labeled as cryptogenic are cardioembolic in origin because of occult AF. 5,6 Furthermore, ≥2 factors contributing to stroke risk may coexist: even patients with an identified risk factor for nonembolic stroke may have occult cardioembolism.Detection rate of new AF from a standard 12-lead ECG after ischemic stroke/transient ischemic attack (TIA) is ≈2% to 5% 7,8 and from 24-hour Holter is 2% to 6%. [9][10][11] The European Stroke Organization 12 and the American Heart Association (AHA)/ American Stroke Association 13 recommend that 24-hour Holter monitoring is used to detect occult AF/PAF when suspected, and no other cause for stroke is found. However, the optimum timing, duration, setting (outpatient or inpatient), and method of monitoring to maximize the detection of PAF after stroke/ TIA are unclear. Furthermore, diagnostic criteria used for PAF during monitoring may vary and have implications for risk of recurrence. We therefore undertook a systematic review and meta-analysis with the following objectives:To determine the overall rate of detection of any new AF with cardiac monitoring (invasive and noninvasive) after ischemic stroke/TIA. To evaluate detection rates of AF in selected versus unselected patients with stroke/TIA. To explore the influence of duration of monitoring on detection rates of AF.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 ev...

Atrial Fibrillation Detection Using a Novel Cardiac Ambulatory Monitor Based on Photo‐Plethysmography at the Wrist

“…Yet, noninvasive ECG monitoring devices available today are cumbersome, costly, and suffer from poor patient adherence. These characteristics limit our capacity to perform long‐term noninvasive investigation for incident or recurrent paroxysmal AF 36, 37. A convenient wrist‐wearable PPG sensor able to detect pulse irregularities attributable to AF could represent a valid solution to assist with screening for AF by providing a comfortable method to identify individuals who might benefit from confirmatory diagnostic ECG testing.…”

Detection and management of atrial fibrillation after cryptogenic stroke or embolic stroke of undetermined source

“…Several monitoring strategies have been investigated to detect asymptomatic AF after an ischemic stroke, including electrocardiography (ECG), in-hospital monitoring, Holter ECG of variable duration, external event or loop recorders, mobile cardiac outpatient telemetry, and implantable cardiac monitors. These studies, and their recent meta-analyses, [7][8][9][10][11][12] contributed significantly to our current understanding of the incidence of AF after ischemic stroke.…”

Silent Atrial Fibrillation: Definition, Clarification, and Unanswered Issues

“…Therefore efforts to standardize such research, establish validated algorithms of investigation in these diverse populations, and assess standardized arrhythmic markers for their prognostic outcomes is badly needed. [12][13][14][15][16] A noncomplete review of arrhythmic markers appearing in the recent medical literature from diverse detection methods on a variety of medical instruments in multiple populations, illustrates and highlights the current existing chaos (Table 1). [20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] Moreover, there is an appreciation that current clinical trials in progress predominantly employ relatively expensive invasive devices that advance our understanding without recognition of perhaps less costly noninvasive methodologies that could be employed if an investigative guideline algorithm existed.…”

“…This presentation seeks to examine this quandary, provide some definitions, and present unanswered issues that need to be addressed by the scientific community at large. The need for such a focus and clarification has been appreciated by many authors recently, [12][13][14][15][16] and should prove valuable for future research of atrial fibrillation.…”