ESC Working Group on e-Cardiology Position Paper: accuracy and reliability of electrocardiogram monitoring in the detection of atrial fibrillation in cryptogenic stroke patients

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.

Prolonged cardiac monitoring for stroke prevention: A systematic review and meta-analysis of randomized-controlled clinical trials

“…Potential biomarkers and risk stratification scores may guide a more individualized approach for selecting patients at stroke risk for PCM as part of primary or secondary stroke prevention management. 16,44,45 Our present meta-analysis includes all RCTs that have been completed to date investigating PCM efficacy in reducing the risk of first-ever or recurrent stroke. In addition, we have included previously unpublished data on stroke occurrence from 3 RCTs.…”

“…Potential biomarkers and risk stratification scores may guide a more individualized approach for selecting patients at stroke risk for PCM as part of primary or secondary stroke prevention management. 16,44,45…”

“…Increasing age, 8,9 left atrial enlargement, 9 cortical location of infarction, 11 an increased number of atrial premature beats per 24 h, 11 risk stratification scores (such as CHA 2 DS 2 -VASc, 4 Brown ESUS-AF, 12 HAVOC, 13 and C 2 HEST 14 scores), have been used in clinical practice for the selection of patients that may require additional investigation or more prolonged monitoring. 15,16 Indeed, the duration of implantable cardiac monitoring (ICM) has been independently associated with the likelihood of AF detection among patients with CS, with ICM duration of <6 and >24 months yielding AF detection rates of 5% and 34% respectively. 8 Nevertheless, whether the detection of subclinical AF through PCM and the subsequent initiation of anticoagulants may lead to stroke prevention remains equivocal.…”

An implantable loop recorder or smartphone based single-lead electrocardiogram to detect arrhythmia in adults with congenital heart disease?

“…Diagnostic yield of prolonged monitoring is also well established in AF screening in cryptogenic stroke patients (27). Longer durations of monitoring were associated with the highest diagnostic yield in these patients (28, 29).…”

Biomarkers predictive of atrial fibrillation in patients with cryptogenic stroke. Insights from the Nordic Atrial Fibrillation and Stroke (NOR‐FIB) study

“…Despite the superiority of ICMs to detect AF in CS patients, the use of ICMs is not broadly implemented in routine diagnostic work‐up, mainly due to increased work‐load and relatively higher initial cost [8]. Better selection of patients for monitoring with ICMs is needed.…”