Long-term detection of atrial fibrillation with insertable cardiac monitors in a real-world cryptogenic stroke population

Ziegler, Paul; Rogers, John; Ferreira, Scott; Nichols, Allan J.; Richards, Mark; Koehler, Jodi; Sarkar, Shantanu

doi:10.1016/j.ijcard.2017.06.039

Cited by 86 publications

(77 citation statements)

References 31 publications

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“…Previous studies reported that the percentages of AF were 16% at 30 days and 21% at 2 years in a population of 280 41 and 1247 32 patients with a recent CS, respectively. At 24 months follow-up, we found a significantly higher DR of AF (41%) in comparison with previous literature (χ 2 = 6.4 p = 0.01 and χ 2 = 4.3 p = 0.04) 32,41 . This result has to be interpreted in light of several considerations.…”

Section: Discussioncontrasting

confidence: 60%

“…Even though in the last decades, randomized and controlled studies had demonstrated the importance of cardiac monitoring via ICMs devices in cryptogenic stroke patients 24,29,30 , there are only a few real-life studies with follow-up longer than 12 months. In a recent study by Ziegler et al 32 AF was diagnosed in 21.5% of CS patients by 24-months follow-up. Our study represents the first real-life cohort of CS patients in Europe with a follow-up longer more than 24 months.…”

Section: Discussionmentioning

confidence: 88%

“…The ICM device (Reveal LINQ, Medtronic) is a small cardiac monitor that is inserted into the subcutaneous tissue over the heart. This device detects and records automatically AF, irrespective of heart rate or symptoms 32 . ICM recordings were monitored constantly to detect possible ECG anomalies during the study.…”

mentioning

confidence: 99%

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Cryptogenic stroke and atrial fibrillation in a real-world population: the role of insertable cardiac monitors

Angelis

Stefano

Franciotti

et al. 2020

Sci Rep

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The incidence of atrial fibrillation (AF) in cryptogenic stroke (CS) patients has been studied in carefully controlled clinical trials, but real-world data are limited. We investigated the incidence of AF in clinical practice among CS patients with an insertable cardiac monitor (ICM) placed for AF detection. Patients with CS admitted to our Stroke Unit were included in the study; they received an ICM and were monitored for up to 3 years for AF detection. All detected AF episodes of at least 120 sec were considered. From March 2016 to March 2019, 58 patients (mean age 68.1 ± 9.3 years, 67% male) received an ICM to detect AF after a CS. No patients were lost to follow-up. AF was detected in 24 patients (41%, AF group mean age 70.8 ± 9.4 years, 62% male) after a mean time of 6 months from ICM (ranging from 2 days to 2 years) and 8 months after CS (ranging from 1 month to 2 years). In these AF patients, anticoagulant treatment was prescribed and nobody had a further stroke. In conclusion, AF episodes were detected via continuous monitoring with ICMs in 41% of implanted CS patients. AF in CS patients is asymptomatic and difficult to diagnose by strategies based on intermittent short-term recordings. Therefore, we suggest that ICMs should be part of daily practice in the evaluation of CS patients. In 20-40% of ischemic strokes, a definitive cause is not identified, despite extensive evaluation 1 ; this condition has been defined as "cryptogenic stroke" (CS) 1-6. Many hypotheses have arisen to find an explanation for the stroke occurrence, but there is no consensus 7. Atrial fibrillation (AF) is a well-known cause of ischemic stroke and about 15% of strokes are attributable to a documented AF 8,9. Moreover, AF is the most common cause of cardioembolism in patients older than 70 10,11. Unfortunately, AF can evade conventional monitoring strategies of patients with acute cerebral ischemia, thus supporting its possible role in CS 12. The diagnosis of AF has clinical relevance, as randomized clinical trials have shown that anticoagulation reduces the risk of stroke in patients with AF 13,14. However, it is required to document AF to initiate anticoagulant therapy after ischemic stroke and, in the absence of documented AF, antiplatelet agents are recommended 15. A diagnosis of AF can influence the management of CS, because the presence of AF changes the pharmacological therapy to anticoagulant prescription. Indeed, it has been shown that anticoagulation is superior than antiaggregation in preventing further strokes in patients with AF 16. The risk of stroke in patients with AF can be estimated by the CHA 2 DS 2-VASc score 17 , but, even in the presence of strong suspicion, AF may not be detected in the acute phase of ischemic stroke, due to its paroxysmal and asymptomatic nature 18-21. For this reason, many strategies have been explored to improve detection of AF, ranging from in-hospital monitoring, serial electrocardiography and Holter monitoring and the use of external events (or loop recorders) or insertable cardiac moni...

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Section: Discussioncontrasting

confidence: 60%

Section: Discussionmentioning

confidence: 88%

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Cryptogenic stroke and atrial fibrillation in a real-world population: the role of insertable cardiac monitors

Angelis

Stefano

Franciotti

et al. 2020

Sci Rep

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“…After 3 years, among patients followed long-term, the rates were 30% and 3%, respectively. These findings were subsequently confirmed in a real-world cryptogenic stroke cohort with suspected AF, with a reported detection rate of 21.5% at 2 years 19 .…”

Section: Introductionsupporting

confidence: 53%

Use of insertable cardiac monitors for the detection of atrial fibrillation in patients with cryptogenic stroke in the United States is cost-effective

Maervoet¹,

Bossers²,

Borge

et al. 2019

Journal of Medical Economics

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Objectives: Atrial fibrillation (AF) is the most common arrhythmia and a major marker of ischemic stroke risk. Early detection is crucial and, once diagnosed, anticoagulation therapy can be initiated to reduce stroke risk. The aim of this study was to assess the cost-effectiveness of employing an insertable cardiac monitor (ICM), BIOMONITOR, for the detection of AF compared to standard of care (SoC) ECG and Holter monitoring in patients with cryptogenic stroke, that is, stroke of unknown origin and where paroxysmal, silent AF is suspected. Materials and methods: A Markov model was developed which consisted of five main health states reflecting the potential lifetime evolution of the AF disease: post cryptogenic stroke (index event), subsequent mild, moderate and severe stroke, and death. Sub-states were included to track a patient's AF diagnostic status and the use of antiplatelet or anticoagulant therapy. AF detection was assumed to result in a treatment switch from aspirin to anticoagulants, except among those with a history of major bleeding. Detection yield and accuracy, clinical actions and treatment effects were derived from the literature and validated by an expert clinician. All relevant costs from a US Medicare perspective were included. Results and conclusions: An ICM-based strategy was associated with a reduction of 37 secondary ischemic strokes per 1000 patients monitored compared with SoC. Total per-patient costs with an ICM were higher (US$90,052 vs. US$85,157) although stroke-related costs were reduced. The use of an ICM was associated with a base-case incremental cost-effectiveness ratio of US$18,487 per life year gained compared with SoC and US$25,098 per quality-adjusted life year gained, below established willingness-to-pay thresholds. The conclusions were found to be robust over a range of input values. From a US Medicare perspective the use of a BIOMONITOR ICM represents a cost-effective diagnostic strategy for patients with cryptogenic stroke and suspected AF. ARTICLE HISTORY

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“…Stroke is the leading cause of death in China and all the world [1], and about 25% strokes are categorized as cryptogenic stroke [2]. However, overdiagnosis of cryptogenic stroke exists actually, as 8.9-16.1% of atrial fibrillation (AF) underdiagnosed was detected when extensive diagnostic 3 investigations such as prolonged cardiac rhythm monitoring were routinely undertaken for cryptogenic stroke patients [3][4][5][6][7][8].…”

Section: Introductionmentioning

confidence: 99%

Influencing factors of AF detection in cryptogenic stroke: A survey among neurologists in China

Bi¹,

He²,

Lu³

et al. 2019

Preprint

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Background and Purpose-Atrial fibrillation (AF) detection is a cornerstone of cardioembolic stroke prevention and is especially recommended in patients initially diagnosed cryptogenic stroke, but few data exist about the extent of AF detection. This study aimed to investigate influencing factors of AF detection for cryptogenic stroke patients from neurologists' perspective. Methods-A questionnaire survey was conducted from October 2016 to March 2018 and included neurologists from 42 hospitals in China. Respondents' demographic characteristics, AF-related knowledge and education, attitude to AF detection and daily AF detection practice were surveyed. Pearson chi-square tests and logistic regression were used to identify neurologists characteristics independently associated with AF detection. Results-611 neurologists were surveyed in this study and 53.0% reported always detecting AF among cryptogenic stroke patients. The main obstacles of AF detection were insufficient knowledge, high expense and inactive attitude. Those who received continuing medical education (training program) about AF detection (OR=2.25, CI[1.57, 3.23], p<0.001), who had positive attitude (OR=3.25,CI [2.24, 4.71], p<0.001) and who acquired graduate degree (OR=2.48, CI[1.21, 5.07], p=0.013) were more likely to detect AF in cryptogenic stroke patients. Neurologists who had worked in neurology over 20 years (OR=3.59, CI[1.61, 8.05], p=0.002), and who received continuing medical education (OR=1.82, CI[1.21, 2.58], p=0.001) were more likely to have an positive attitude to AF detection.Conclusions-Our survey suggested inadequate AF detection among neurologists, and continuing medical education was associated with neurologists' attitude and AF detection behavior. More continuing medical education is required to increase the effective detection of AF and improve the quality of clinical practice.

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Long-term detection of atrial fibrillation with insertable cardiac monitors in a real-world cryptogenic stroke population

Cited by 86 publications

References 31 publications

Cryptogenic stroke and atrial fibrillation in a real-world population: the role of insertable cardiac monitors

Cryptogenic stroke and atrial fibrillation in a real-world population: the role of insertable cardiac monitors

Use of insertable cardiac monitors for the detection of atrial fibrillation in patients with cryptogenic stroke in the United States is cost-effective

Influencing factors of AF detection in cryptogenic stroke: A survey among neurologists in China

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