Optimal Duration of Monitoring for Atrial Fibrillation in Cryptogenic Stroke: A Nonsystematic Review

Abstract

Atrial fibrillation (AF) is the most common form of cardiac arrhythmias and an independent risk factor for stroke. Despite major advances in monitoring strategies, clinicians tend to miss the diagnoses of AF and especially paroxysmal AF due mainly to its asymptomatic presentation and the rather limited duration dedicated for monitoring for AF after a stroke, which is 24 hours as per the current recommended guidelines. Hence, determining the optimal duration of monitoring for paroxysmal atrial fibrillation after acute ischemic stroke remains a matter of debate. Multiple trials were published in regard to this matter using both invasive and noninvasive monitoring strategies for different monitoring periods. The data provided by these trials showcase strong evidence suggesting a longer monitoring strategy beyond 24 hours is associated with higher detection rates of AF, with the higher percentage of patients detected consequently receiving proper secondary stroke prevention with anticoagulation and thus justifying the cost-effectiveness of such measures. Overall, we thus conclude that increasing the monitoring duration for AF after a cryptogenic stroke to at least 72 hours will indeed enhance the detection rates, but the cost-effectiveness of this monitoring strategy compared to longer monitoring durations is yet to be established.

Practice Patterns for Acute Ischemic Stroke Workup: A Longitudinal Population‐Based Study

“…It is unclear whether our practice patterns, patient demographics, and health care system characteristics are generalizable to other regions, although we know, based on census data, that our region is representative of the United States with regard to median age, percentage of black persons, median household income, and percentage of the population below the poverty level (Table 4). Second, with respect to detection of paroxysmal AF, it is known that transthoracic echocardiogram and a single ECG are not sensitive 8. A limitation of our study is that we did not have data on the frequency of telemetry use on the inpatient stroke unit for all study periods or on discharge with Holter or 30‐day event monitors.…”

“…A recent meta‐analysis found that increasing use of antiplatelet drugs and antihypertensive medications was associated with this decline,8 although a causal relationship clearly cannot be determined. It may also be speculated that carotid endarterectomy and anticoagulation have reduced recurrent strokes in patients with high‐grade carotid stenosis and AF, respectively.…”

“…Second, with respect to detection of paroxysmal AF, it is known that transthoracic echocardiogram and a single ECG are not sensitive. 8 A limitation of our study is that we did not have data on the frequency of telemetry use on the inpatient stroke unit for all study periods or on discharge with Holter or 30-day event monitors. Transthoracic echocardiogram use, however, would evaluate for focal wall motion abnormalities, intracardiac shunts, thrombi, or valvular abnormalities, all of which could lead to cardioembolism.…”

Atrial fibrillation and cryptogenic stroke. What is the current evidence? Role of electrocardiographic monitoring

“…There are other proposed schemes for prediction of paroxysmal AF following an ischemic stroke. One of the best one studied is the iPAB score, which includes a personal history of arrhythmia or antiarrhythmic drug use, atrial dilatation, and elevation of brain natriuretic peptide …”

“…One of the best one studied is the iPAB score, which includes a personal history of arrhythmia or antiarrhythmic drug use, atrial dilatation, and elevation of brain natriuretic peptide. 15 The evidence regarding the monitoring time to be employed in patients with CS for detecting AF is still inconclusive. A recent consensus document recommends "extended ECG monitoring" in patients with CS to detect undiagnosed AF.…”