B-PO01-028 UTILIZATION OF CARDIAC MONITORING FOR ATRIAL FIBRILLATION IN CRYPTOGENIC STROKE PATIENTS

Introduction: Approximately 25% of strokes are classified as cryptogenic (CS), while greater than 50% have an identifiable or ‘known’ etiology (KS). Several studies have demonstrated that prolonged cardiac monitoring (PCM) after cryptogenic stroke substantially increases the detection of atrial fibrillation (AF), but the yield of PCM in KS stroke is unknown. As a result, the majority of guidelines recommend restricting PCM to patients with cryptogenic stroke. If the detection of AF in KS is no different to cryptogenic stroke, it would suggest that this group too would similarly benefit from PCM, with the potential to impact therapeutic decisions (e.g. initiating anticoagulation). Methods: In a cross-sectional study, we compared AF detection by PCM (minimum of 48 hrs) between CS and KS patients without a previous diagnosis of AF. We developed a multivariate logistic regression model by including known and significant clinical, echocardiographic, and radiological factors known to be associated with the detection of AF. We reported results as odds ratios (OR) and 95% confidence intervals (95% CI). Results: We included 561 ischemic stroke patients, 376 with CS and 185 with KS. The median duration of PCM was 167h for CS and 48h for KS. AF was detected in 30 of 376 (8%) CS patients, and 20 of 185 (7.9%) KS patients. Age, history of thyroid disease, clinical presentation of dysarthria, wake-up stroke, and left atrial volume index on echocardiography were significantly associated with a new diagnosis of AF after stroke in the univariable analysis and were thus included in the logistic regression analysis. Additionally, duration of PCM was included in the multivariate model. After adjustment for potential confounders, AF detection by PCM was not significantly higher for CS than KS (OR 0.95, 95% CI 0.25-3.32, P=0.94). Conclusion: To the best of our knowledge this is the first study directly comparing the incidence of AF between CS and KS as the pre-specified primary outcome. Our findings suggest that CS and KS patients have similar rates of AF detection by PCM. Future prospective research is required to confirm these findings and to determine the cost-effectiveness of PCM in non-cryptogenic stroke patients.

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Frequent Premature Atrial Contractions in Cryptogenic Stroke Predict Atrial Fibrillation Detection with Insertable Cardiac Monitoring

Cerebrovascular Diseases ◽

10.1159/000505958 ◽

2020 ◽

Vol 49 (2) ◽

pp. 144-150 ◽

Cited By ~ 2

Author(s):

Kenichi Todo ◽

Tomonori Iwata ◽

Ryosuke Doijiri ◽

Hiroshi Yamagami ◽

Masafumi Morimoto ◽

...

Keyword(s):

Atrial Fibrillation ◽

High Frequency ◽

Strong Predictor ◽

Cryptogenic Stroke ◽

High Plasma ◽

Cardiac Monitoring ◽

Stroke Patients ◽

Chads2 Score ◽

Index Stroke

Objective: To determine whether frequent premature atrial contractions (PAC) predict atrial fibrillation (AF) in cryptogenic stroke patients, we analyzed the association between frequent PACs in 24-h Holter electrocardiogram recording and AF detected by insertable cardiac monitoring (ICM). Methods: We retrospectively analyzed a database of 66 consecutive patients with cryptogenic stroke who received ICM implantation between October 2016 and March 2018 at 5 stroke centers. We included the follow-up data until June 2018 in this analysis. We defined frequent PACs as the upper quartile of the 66 patients. We analyzed the association of frequent PACs with AF detected by ICM. Results: Frequent PACs were defined as >222 PACs per a 24-h period. The proportion of patients with newly detected AF by ICM was higher in patients with frequent PACs than those without (50% [8/16] vs. 22% [11/50], p < 0.05). Frequent PACs were associated with AF detection and time to the first AF after adjustment for CHADS2 score after index stroke, high plasma B-type natriuretic peptide (BNP; >100 pg/mL) or serum N-terminal pro-BNP levels (>300 pg/mL), and large left atrial diameter (≥45 mm). Conclusion: High frequency of PACs in cryptogenic stroke may be a strong predictor of AF detected by ICM.

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Abstract WP255: Can Normal Electrocardiogram Rule Out Newly Diagnosed Atrial Fibrillation in Ischemic Stroke Patients

Stroke ◽

10.1161/str.51.suppl_1.wp255 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Joshua Santucci ◽

Takashi Shimoyama ◽

Ken Uchino

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cryptogenic Stroke ◽

Cardiac Monitoring ◽

Large Artery ◽

Newly Diagnosed ◽

Stroke Patients ◽

Stroke Subtype ◽

History Of

Introduction: Electrocardiogram (ECG) findings of premature atrial contraction and prolonged PR interval are associated with risk of onset atrial fibrillation (AF) in cryptogenic stroke. We sought to see if normal ECG and AF incidence is incompletely understood. Methods: From a prospective single-hospital stroke registry from 2018, we identified ischemic stroke patients who had ECG done on admission for review. We excluded patients with AF on admission ECG, history of AF, and implanted device with cardiac monitoring capability. Normal ECG was interpreted based on the standardized reporting guidelines for ECG studies evaluating risk stratification of emergency department patients. Stroke subtype was diagnosed according to the TOAST classification: large artery atherosclerosis (LAA), small vessel occlusion (SVO), cardioembolism, others/undetermined and embolic stoke of undetermined source (ESUS) criteria. We compared the incidence of newly diagnosed AF during hospitalization and from outpatient cardiac event monitoring between normal and abnormal ECG. Results: Of the 558 consecutive acute ischemic stroke patients, we excluded 135 with AF on admission ECG or history of AF and 9 with implanted devices. Of the remaining 414 patients that were included in the study, ESUS (31.2%) was the most frequent stroke subtype, followed by LAA (30.0%), SVO (14.0%), others/undetermined (15.7%), and cardioembolism (9.2%). Normal ECG was observed in 125 patients (30.2%). Cardioembolic subtype was less frequent in the normal versus abnormal ECG group (1.6% vs. 12.5%, p<0.001). New AF was detected in 17/414 patients (4.1%) during hospitalization. Of these 17 patients, none had normal ECG (0/125) and all had abnormal ECG (17/289, 5.9%) (p=0.002). After discharge, of 111 patients undergoing 4-week outpatient cardiac monitoring, new AF was detected in 16 (14.4%). Of these 16 patients, only 1 had a normal ECG (1/35, 2.9%) while 15 had abnormal ECG (15/76, 19.7%) (p=0.02). Conclusions: Normal ECG at admission for acute ischemic stroke is associated with low likelihood of detection of new atrial fibrillation in either the inpatient or outpatient setting.

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LOW INCIDENCE OF ATRIAL FIBRILLATION IN RECURRENT STROKES IN A COHORT OF CRYPTOGENIC STROKE PATIENTS ON LONG TERM CARDIAC MONITORING

10.26226/morressier.5ab8f55cd462b8029238c872 ◽

2018 ◽

Author(s):

pramod sethi

Keyword(s):

Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Cardiac Monitoring ◽

Stroke Patients ◽

Recurrent Strokes ◽

Low Incidence

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Abstract WMP69: Differential Risk Factor Profile in Cryptogenic Stroke Patients May Help Identify High Yield Candidates for Long-term Cardiac Monitoring in Detection of Paroxysmal Atrial Fibrillation

Stroke ◽

10.1161/str.50.suppl_1.wmp69 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Jindong Xu ◽

Sharon Biby ◽

Pramod Sethi

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Paroxysmal Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Cardiac Monitoring ◽

High Yield ◽

Stroke Patients ◽

Risk Factor Profile ◽

Differential Risk

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Different aspects of early and late development of atrial fibrillation during hospitalization in cryptogenic stroke

Scientific Reports ◽

10.1038/s41598-021-86620-5 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Ryosuke Doijiri ◽

Yuji Ueno ◽

Muneaki Kikuno ◽

Takahiro Shimizu ◽

Yohei Tateishi ◽

...

Keyword(s):

Atrial Fibrillation ◽

Multiple Logistic Regression Analysis ◽

Cryptogenic Stroke ◽

Cardiac Monitoring ◽

Late Development ◽

Multiple Logistic Regression ◽

Stroke Patients ◽

Late Stages ◽

Late Detection ◽

Multicenter Registry

AbstractThe detection of underlying atrial fibrillation (AF) has become increasingly possible by insertable cardiac monitoring (ICM). During hospitalization for cryptogenic stroke, factors related to the early and late development of AF have not been studied. CHALLENGE ESUS/CS is a multicenter registry of cryptogenic stroke patients undergoing transesophageal echocardiography. Twelve-lead electrocardiogram, continuous cardiac monitoring, and 24-h Holter electrocardiogram were all used for the detection of AF. Early and late detection of AF was determined with an allocation ratio of 1:1 among patients with AF. A total of 677 patients (68.7 ± 12.8 years; 455 men) were enrolled, and 64 patients developed AF during hospitalization. Four days after admission was identified as the approximate median day to classify early and late phases to detect AF: ≤ 4 days, 37 patients; > 4 days, 27 patients. Multiple logistic regression analysis showed that spontaneous echo contrast (SEC) (OR 5.91; 95% CI 2.19–15.97; p < 0.001) was associated with AF ≤ 4 days, whereas a large infarction > 3 cm in diameter (OR 3.28; 95% CI 1.35–7.97; p = 0.009) was associated with AF > 4 days. SEC and large infarctions were important predictors of in-hospital AF detection, particularly in the early and late stages, respectively; thus, they could serve as indications for recommending ICM.

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Long-term Cardiac Monitoring for Detection of Occult Atrial Fibrillation – A Tool to Prevent Secondary Stroke in Cryptogenic Stroke Patients

European Neurological Review ◽

10.17925/enr.2014.09.01.ia ◽

2014 ◽

Vol 9 (1) ◽

pp. i

Author(s):

Joerg Berrouschot ◽

Keyword(s):

Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Randomised Clinical Trial ◽

Cardiac Monitoring ◽

Monitoring Methods ◽

Stroke Patients ◽

Current Review ◽

Life Saving ◽

To Receive

Stroke kills or disables millions of people every year. If the cause of a stroke is known, it is often possible to reduce the risk of a second stroke by appropriate patient management. However, up to a third of all ischaemic strokes remain cryptogenic, with no identified cause. Many of these strokes are suspected to be due to atrial fibrillation (AF), which is difficult to diagnose accurately. Small, leadless, insertable cardiac monitors (ICMs) gather data over three years, making them superior to other monitoring methods. The current review surveys the substantial supporting clinical data for the ICM Reveal XT, including the recently completed CRYSTAL-AF randomised clinical trial. The results consistently report previously undiagnosed AF in around 30 % of patients with cryptogenic stroke. ICM-provided data have direct consequences, as patients with AF-related stroke are indicated for protective oral anticoagulant therapies. Thus, ICMs will be important in the management of cryptogenic stroke, identifying and enabling patients with AF to receive life-saving therapies.

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Investigating the Occult

10.1093/med/9780190495541.003.0016 ◽

2016 ◽

Author(s):

Ji Y. Chong ◽

Michael P. Lerario

Keyword(s):

Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Cardiac Monitoring ◽

Stroke Patients ◽

Arrhythmia Detection ◽

Implantable Loop Recorders

Occult atrial fibrillation is more common than previously thought in patients with cryptogenic stroke, particularly in older cohorts. If stroke patients are suspected to have atrial fibrillation, intensive cardiac monitoring using implantable loop recorders or prolonged external monitors should be ordered and can result in higher rates of arrhythmia detection.

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Abstract P624: High Detection of Atrial Fibrillation by 90 Days Textil Holter Monitoring in Patients With Cryptogenic Stroke

Stroke ◽

10.1161/str.52.suppl_1.p624 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Jorge Pagola ◽

Jesus Juega ◽

Jaume Francisco ◽

Maite Rodriguez ◽

Juan Antonio Cabezas ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cumulative Incidence ◽

Left Atrial ◽

Cryptogenic Stroke ◽

Left Atrial Volume ◽

Holter Monitoring ◽

Cardiac Monitoring ◽

Atrial Volume ◽

Monitoring Time ◽

Number Of Patients

Introduction: External recorders allow for low-cost, non-invasive 1 to 4 weeks monitoring. However, the first 3 months of monitoring duration are the most effective to detect atrial fibrillation (AF). We show the results of the Thunder registry of patients monitored to detect AF during 90 days from the stroke. Methods: A prospective observational study was conducted with consecutive inclusion of patients with cryptogenic stroke after work up (neuroimaging, echocardiography and 24-hour cardiac monitoring) in 5 Comprenhensive Stroke Centers. Patients were continuously monitored for 90 days with a wearable Holter (Nuubo®) after the first 24 hours of the stroke onset. We analyzed the percentage of AF detection in each period (percentage of AF among those monitored), the quality of the monitoring (monitoring time), the percentage of AF by intention to monitor (detection of AF among patient included). Demographic, clinical and echocardiographic predictors of AF detection beyond one week of cardiac monitoring were assessed. Results: A total of 254 patients were included. The cumulative incidence of AF detection at 90 days was 34.84%. The monitoring time was similar among the 3 months (30 days: 544.9 hours Vs 60 days: 505.9 hours Vs 90 days: 591.25 hours) (p=0.512). The number of patients who abandoned monitoring was 7% (18/254). The cumulative percentage of intention to detect AF was 30.88% (Figure). Patients who completed monitoring beyond 30 days had higher score on the NIHSS basal scale (NIHSS 9 IQR 2-17) VS (NIHSS 3 IQR 1-9) (p=0.024). Patients with left atrial volume greater than 28.5ml/m2 had higher risk of cumulative incidence of AF according to the Kaplan Meyer curve beyond the first week of monitoring OR 2.72 (Log-rank (Mantel-Cox test) (p<0.001). Conclusions: In conclusion, intensive 90-day- Holter monitoring with textile Holter was feasible and detected high percentage of AF. Enlarged left atrial volume predicted AF beyond the first week of monitoring.

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Predictors of Occult Paroxysmal Atrial Fibrillation in Cryptogenic Strokes Detected by Long-Term Noninvasive Cardiac Monitoring

Stroke Research and Treatment ◽

10.4061/2011/172074 ◽

2011 ◽

Vol 2011 ◽

pp. 1-5 ◽

Cited By ~ 14

Author(s):

Archit Bhatt ◽

Arshad Majid ◽

Anmar Razak ◽

Mounzer Kassab ◽

Syed Hussain ◽

...

Keyword(s):

Atrial Fibrillation ◽

Paroxysmal Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Cardiac Monitoring ◽

High Signal ◽

Detection Rates ◽

Non Invasive ◽

Patient Reported ◽

Premature Beats

Background and Purpose. Paroxysmal Atrial fibrillation/Flutter (PAF) detection rates in cryptogenic strokes have been variable. We sought to determine the percentage of patients with cryptogenic stroke who had PAF on prolonged non-invasive cardiac monitoring.Methods and Results. Sixty-two consecutive patients with stroke and TIA in a single center with a mean age of 61 (+/− 14) years were analyzed. PAF was detected in 15 (24%) patients. Only one patient reported symptoms of shortness of breath during the episode of PAF while on monitoring, and 71 (97%) of these 73 episodes were asymptomatic. A regression analysis revealed that the presence of PVCs (ventricular premature beats) lasting more than 2 minutes (OR 6.3, 95% CI, 1.11–18.92;P=.042) and strokes (high signal on Diffusion Weighted Imaging) (OR 4.3, 95% CI, 5–36.3;P=.041) predicted PAF. Patients with multiple DWI signals were more likely than solitary signals to have PAF (OR 11.1, 95% CI, 2.5–48.5,P<.01).Conclusion. Occult PAF is common in cryptogenic strokes, and is often asymptomatic. Our data suggests that up to one in five patients with suspected cryptogenic strokes and TIAs have PAF, especially if they have PVCs and multiple high DWI signals on MRI.

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