Role of Outpatient Cardiac Rhythm Monitoring in Cryptogenic Stroke: A Systematic Review and Meta‐Analysis

Afzal, Muhammad R.; Gunda, Sampath; Waheed, Salman; Sehar, N.; Maybrook, Ryan; Dawn, Buddhadeb; Lakkireddy, Dhanunjaya

doi:10.1111/pace.12688

Cited by 42 publications

(31 citation statements)

References 34 publications

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“…The 2014 AHA/ASA stroke prevention guidelines recommend 30 days of cardiac monitoring for patients with cryptogenic stroke or TIA when performed within 6 months of the event (class IIa; level of evidence C) [5]. The available literature and several recent meta-analyses clearly demonstrate that longer cardiac monitoring results in greater atrial fibrillation detection [3,46,47]. This is demonstrated nicely in the SMART registry, where 45 % of new AF occurred in the first 10 days of monitoring, 31 % in the next 10 days, and 24 % in the last 10 days [25].…”

Section: Duration Of Monitoringmentioning

confidence: 98%

Paroxysmal Atrial Fibrillation: Novel Strategies for Monitoring and Implications for Treatment in Stroke

Silverman

2016

Curr Treat Options Cardio Med

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In cryptogenic stroke, prolonged cardiac monitoring is often employed to search for and diagnose atrial fibrillation (AF). Multiple monitoring modalities with multiple durations of monitoring exist. Finding atrial fibrillation after an ischemic stroke is extremely important as anticoagulation is the standard of care and results in the lowest stroke recurrence rate. The protocol at our institution is to carry out 30-day mobile cardiac outpatient telemetry (MCOT) in all patients with cryptogenic stroke. If this MCOT fails to reveal AF, yet the suspicion is high based on the presence of clinical, biochemical, electrocardiographic, and echocardiographic factors, we may proceed to use an implantable cardiac monitor. When AF is diagnosed after cryptogenic stroke, regardless of its duration and assuming no contraindications exist, anticoagulation is recommended with either warfarin or one of the DOACs (direct oral anticoagulants).

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Section: Duration Of Monitoringmentioning

confidence: 98%

Paroxysmal Atrial Fibrillation: Novel Strategies for Monitoring and Implications for Treatment in Stroke

Silverman

2016

Curr Treat Options Cardio Med

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“…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.…”

Section: Stroke Recurrence In Patients With Prior Cs and Esusmentioning

confidence: 99%

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

Sanna

Ziegler

Crea

2018

Clinical Cardiology

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Cryptogenic stroke (CS) and embolic stroke of unknown source (ESUS) represent a major challenge to healthcare systems worldwide. Atrial fibrillation (AF) is commonly found after CS or ESUS. Independent of the mechanism of the index CS or ESUS, detection of AF in these patients offers the opportunity to reduce the risk of stroke recurrence by prescribing an anticoagulant instead of aspirin. The detection of AF may be pursued with different monitoring strategies. Comparison of monitoring strategies should take into account that AF detection rates reported in published studies, and then pooled in meta-analyses, are not only a function of the monitoring strategy itself, but also depend on patient-related, device-related, and study design-related factors. Once AF is found, the decision to anticoagulate a patient should be made on the basis of AF burden and the baseline risk of the patient. Empirical anticoagulation in patients with ESUS and no evidence of AF is an intriguing but still-unproven strategy and therefore should not be adopted outside of randomized clinical trials.Each year, >790 000 people experience a new or recurrent stroke in the United States. 1 The cause of ischemic stroke remains undetermined after hospitalization in 10% to 40% of cases; this is often referred to as "cryptogenic" stroke (CS). 2 Differences in the definition and diagnostic workup contribute to this variable incidence in published series. To mitigate this limitation, the term "embolic stroke of undetermined source" (ESUS) has recently been proposed to identify those cases where the etiology of nonlacunar ischemic stroke remains elusive after a standardized diagnostic pathway. 3 The prevalence of ESUS was 16% to 32% in a recently published series. 4 Hence, even after a standardized comprehensive evaluation, the cause of ischemic stroke remains elusive in a significant proportion of patients, thus representing a major challenge for treatment selection. | STROKE RECURRENCE IN PATIENTS WITH PRIOR CS AND ESUSIn a recent study, patients with CS had an ischemic stroke recurrence rate of 9.1% (range, 6.2%-12.0%), 24.0% (range, 19.1%-28.9%), and 31.9% (range, 25.2%-38.6%) at 1, 5, and 10 years, respectively. 5 Recurrent stroke in these patients was classified again as cryptogenic in 63% of cases. 5 Stroke recurrence rate in ESUS was also reported to be high and similar to CS. 6 Possible causes of stroke recurrence, irrespective of the mechanism of the index stroke, are paroxysmal atrial fibrillation (AF), arterial sources of thromboembolism (TE), patent foramen ovale (PFO), cardiac structural abnormalities, and other less common etiologies. Detection of AF after a CS or ESUS does not imply causality but still offers an opportunity for reducing the risk of stroke recurrence by prescribing oral anticoagulation (OAC). However, AF is often asymptomatic, paroxysmal, and difficult to detect with conventional tools. Several monitoring strategies have been investigated to detect asymptomatic AF after an ischemic stroke, including electrocardiography (...

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“…Prolonged cardiac monitoring for up to 3 years post‐stroke has been shown to have 10 times the rate of detection of paroxysmal AF (PAF) compared with short‐term and intermittent monitoring . A 2015 systematic review of cardiac monitoring similarly supported a near doubled PAF detection rate with implantable or insertable cardiac monitors, also known as ILR compared with wearable devices . In 2019, ILR are small minimally invasive devices which can be implanted subcutaneously with a minor procedure.…”

Section: Prolonged Cardiac Monitoringmentioning

confidence: 99%

“…17 A 2015 systematic review of cardiac monitoring similarly supported a near doubled PAF detection rate with implantable or insertable cardiac monitors, also known as ILR compared with wearable devices. 18 In 2019, ILR are small minimally invasive devices which can be implanted subcutaneously with a minor procedure. Thresholds can be set to alert patients and clinicians when PAF of 30 s or greater is detected.…”

Section: Prolonged Cardiac Monitoringmentioning

confidence: 99%

Secondary prevention of ischaemic stroke

Muller

Roizman

Wong

2019

Internal Medicine Journal

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Recent trials within the past few years have influenced not only how we treat patients immediately after acute ischaemic stroke, but also how we investigate for aetiology. With the advent of improved medications, procedures and monitoring devices, modern stroke prevention strategies are more individualised, but the decision‐making process is more complex. We provide an approach to navigating these management options.

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Role of Outpatient Cardiac Rhythm Monitoring in Cryptogenic Stroke: A Systematic Review and Meta‐Analysis

Abstract: AF detection in patients with CS is improved with prolonged rhythm monitoring and is better with ILR compared to wearable devices. AF was more common in older patients. The clinical significance of these findings is unknown at this point.

Cited by 42 publications

References 34 publications

Paroxysmal Atrial Fibrillation: Novel Strategies for Monitoring and Implications for Treatment in Stroke

Paroxysmal Atrial Fibrillation: Novel Strategies for Monitoring and Implications for Treatment in Stroke

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

Secondary prevention of ischaemic stroke

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