Detection of subclinical atrial fibrillation after cryptogenic stroke using implantable cardiac monitors

Ungar, Andrea; Pescini, Francesca; Rafanelli, Martina; Angelis, Maria Vittoria De; Faustino, Massimiliano; Tomaselli, Caterina; Petrone, Alfredo; Forleo, Giovanni B.; Morani, Giovanni; Forlivesi, Stefano; Molon, Giulio; Adami, Alessandro; Maines, Massimiliano; Stegagno, Chiara; Poggesi, Anna; Pantoni, Leonardo

doi:10.1016/j.ejim.2021.06.022

Cited by 19 publications

(15 citation statements)

References 37 publications

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“…Our study confirms the frequent occurrence of unrecognized stroke etiology among patients hospitalized for acute ischemic stroke, with up to one-fourth having no definite recognizable cause at discharge even after an extensive diagnostic workup. In line with other results from previous observational studies, prolonged cardiac monitoring by means of ICM allowed the detection of subclinical AF in one-third of our cryptogenic stroke patients, with roughly half of the diagnoses made in the first 5 months after the implantation [ 17 ]. Indeed, the ICMs have specific AF detection algorithms allowing better estimation of the arrhythmic burden as compared with intermittent monitoring approaches [ 20 ].…”

Section: Discussionsupporting

confidence: 87%

“…During this time, all transmissions with AF events notified by the device (≥ 2 min in duration), as per device related algorithms, were reviewed by an experienced cardiologist to rule out false alarms and eventually make the diagnosis of AF. Diagnostic criteria for ICM-detected subclinical AF, the devices used, and the implantation procedures have been thoroughly described in previous works [ 17 ].…”

Section: Methodsmentioning

confidence: 99%

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Etiologic reclassification of cryptogenic stroke after implantable cardiac monitoring and computed tomography angiography re-assessment

et al. 2022

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Introduction Different mechanisms may underlie cryptogenic stroke, including subclinical atrial fibrillation (AF), nonstenotic carotid plaques (NCP), and aortic arch atherosclerosis (AAA). In a cohort of cryptogenic stroke patients, we aimed to: (1) evaluate the prevalence of subclinical AF, NCP, and AAA, and reclassify the etiology accordingly; (2) compare the clinical features of patients with reclassified etiology with those with confirmed cryptogenic stroke. Methods Data of patients hospitalized for cryptogenic stroke between January 2018 and February 2021 were retrospectively analyzed. Patients were included if they received implantable cardiac monitoring (ICM) to detect subclinical AF. Baseline computed tomography angiography (CTA) was re-evaluated to assess NCP and AAA. Since aortic plaques with ulceration/intraluminal thrombus were considered pathogenetic during the initial workup, only patients with milder AAA were included. Stroke etiology was reclassified as “cardioembolic”, “atherosclerotic”, or “mixed” based on the detection of AF and NCP/AAA. Patients with “true cryptogenic” stroke (no AF, ipsilateral NCP, or AAA detected) were compared with those with reclassified etiology. Results Among 63 patients included, 21 (33%) were diagnosed with AF (median follow-up time of 15 months), 12 (19%) had ipsilateral NCP, and 6 (10%) had AAA. Stroke etiology was reclassified in 30 patients (48%): cardioembolic in 14 (22%), atherosclerotic in 9 (14%), and mixed in 7 (11%). Patients with true cryptogenic stroke were younger compared to those with reclassified etiology (p = 0.001). Discussion One or more potential covert stroke sources can be recognized in half of the patients with a cryptogenic stroke through long-term cardiac monitoring and focused CTA re-assessment.

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Section: Discussionsupporting

confidence: 87%

Section: Methodsmentioning

confidence: 99%

Etiologic reclassification of cryptogenic stroke after implantable cardiac monitoring and computed tomography angiography re-assessment

et al. 2022

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“…Abnormalities in ECG or 24-h Holter monitoring related to LA dysfunction have been associated with an increased yield of AF detection during prolonged monitoring of patients with TIA or stroke of undetermined origin. These include premature atrial complexes on ECG, 29,43,61,73,100,110,126,127 excessive supraventricular electric activity, 70 atrial ectopic burden, 48 P terminal force in the precordial lead V1, 128 P wave dispersion >40 ms, 32 increased maximum P-wave duration, 52 sinus bradycardia, 31 prolonged PR interval 62 and interatrial conduction block 100 (Figure e13 in the Supplemental File).…”

Section: Resultsmentioning

confidence: 99%

European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin

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Antonenko

et al. 2022

European Stroke Journal

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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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“…Lower, but still high detection rates were presented in a study of Ungar et al [20]. The investigators implanted insertable cardiac monitors in 334 patients with cryptogenic stroke.…”

Section: Prevalence Of Subclinical Atrial Fibrillation and Atrial Hig...mentioning

confidence: 98%

“…In recent years, several studies have been undertaken to improve the detection of AF. At the same time, patients with cardiac implantable electronic devices or insertable cardiac monitors have become the focus of interest, as continuous rhythm monitoring is possible in these patients [12,[16][17][18][19][20]. The prevalence of atrial high-rate episodes and subclinical AF in these patients is high (20-70%) but the clinical implications are uncertain [11,[21][22][23].…”

Section: Introductionmentioning

confidence: 99%

How should I treat patients with subclinical atrial fibrillation and atrial high-rate episodes? Current evidence and clinical importance

2022

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Long-term and continuous ECG monitoring using cardiac implantable electronic devices and insertable cardiac monitors has improved the capability of detecting subclinical atrial fibrillation (AF) and atrial high-rate episodes. Previous studies demonstrated a high prevalence (more than 20%) in patients with cardiac implantable electronic devices or insertable cardiac monitors. Subclinical AF and atrial high-rate episodes are often suspected as the cause of prior or potential future ischemic stroke. However, the clinical significance is still uncertain, and the evidence is limited. This review aims to present and discuss the current evidence on the clinical impact of subclinical AF and atrial high-rate episodes. It focuses particularly on the association between the duration of the episodes and major clinical outcomes like thromboembolic events. As subclinical AF and atrial high-rate episodes are presumed to be associated with ischemic strokes, detection will be particularly important in patients with cryptogenic stroke and in high-risk patients for thromboembolism. In this context, it is also interesting whether there is a temporal relationship between the detection of subclinical AF and atrial high-rate episodes and the occurrence of thromboembolic events. In addition, the review will examine the question whether there is a need for a therapy with oral anticoagulation. Graphical abstract

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Detection of subclinical atrial fibrillation after cryptogenic stroke using implantable cardiac monitors

Cited by 19 publications

References 37 publications

Etiologic reclassification of cryptogenic stroke after implantable cardiac monitoring and computed tomography angiography re-assessment

Etiologic reclassification of cryptogenic stroke after implantable cardiac monitoring and computed tomography angiography re-assessment

European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin

How should I treat patients with subclinical atrial fibrillation and atrial high-rate episodes? Current evidence and clinical importance

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