The Evolution and Application of Cardiac Monitoring for Occult Atrial Fibrillation in Cryptogenic Stroke and TIA

Abstract

The evaluation of the stroke and transient ischemic attack (TIA) patient has been historically predominated by the initial evaluation in the hospital setting. As the etiology of stroke has eluded us in approximately one third of all acute events, the medical community has been eager to seek the answer to this mystery. In recent years, we have seen an explosion of innovations and trends allowing for a more detailed post stroke assessment strategy aimed at the identification of occult atrial fibrillation as the etiologic cause for the cryptogenic event. This has been achieved through the evolution and aggressive application and study of prolonged and advanced cardiac monitoring. This review is aimed to clarify and elucidate the standard and novel cardiac monitoring methods that have become available for use by the medical community and expected in the higher level care of cryptogenic stroke and TIA patients. These cardiac monitoring methods and devices are as heterogeneous as our patient population and have their own advantages and disadvantages. Many factors may be taken into consideration in choosing the appropriate cardiac monitoring method and are highlighted for consideration in this review. With a judicious approach to investigating the cryptogenic stroke population, and applying a wealth of novel treatment options, we may move forward into a new era of stroke prevention.

Electrocardiogram modeling during paroxysmal atrial fibrillation: application to the detection of brief episodes

“…Evidence shows that brief episodes progress to longer episodes (Wijffels et al 1995, Kerr et al 2005), implying that it is of interest to evaluate detection performance as a function of episode duration. Moreover, brief but rare episodes have been observed in patients after cryptogenic stroke and transient ischemic attack (Tayal et al 2008, Favilla et al 2015, Keach et al 2015, Miller et al 2016. Such signals can be simulated with the present model using, for example, a median episode duration of 30 beats and a low AF burden of 0.001.…”

Recent advances in the management of transient ischemic attacks

“…As for cardiogenic TIA, the introduction of TEE represents a major diagnostic advancement due to a) increased resolution and sensitivity for left atrial pathology, including the left atrial appendage and the interatrial septum, and b) capability for imaging the aortic arch, uncovering the presence of complex atherosclerotic plaques as a source of artery-to-artery cerebral embolism 80 – 82 , 84 , 85 . Finally, the detection of occult paroxysmal AF in patients with unexplained events correlates with the length of the cardiac rhythm assessment 86 , improved by 7- to 30-day cardiac event monitors 96 – 101 and even more so by implantable loop recorders 83 , 97 – 99 , 101 .…”

An Arrhythmia classification approach via deep learning using single-lead ECG without QRS wave detection

“…For example, nonsustained ventricular tachycardia ( NSVT ) occurs within a few seconds and then returns to a normal rhythm [ 5 ]; thus, it is rarely recorded on a 12-lead ECG. Traditionally, the Holter examination is arranged for high-risk patients, wherein patients must wear a device for 24 h, which is inconvenient and inefficient in an emergency setting [ 6 ]. While ECG is currently the best way to diagnose arrhythmias, early detection can be challenging due to the possibility of it being asymptomatic.…”