Atrial fibrillation in patients with embolic stroke of undetermined source during 3 years of prolonged monitoring with an implantable loop recorder

2021 ◽  
Author(s):  
Alkisti Kitsiou ◽  
Andreas Rogalewski ◽  
Malik Kalyani ◽  
Sameera Deelawar ◽  
Sona Tribunyan ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulation ◽  
Recurrent Stroke ◽  
Cardiac Monitoring ◽  
Stroke Recurrence ◽  
Implantable Loop Recorder ◽  
Loop Recorder ◽  
Complete Work ◽  
Clinical Consequences ◽  
Aortic Plaques

Background: Undocumented atrial fibrillation (AF) is suspected as a main stroke cause in patients with ESUS, but its prevalence is largely unknown. This prospective study therefore aimed at delineating the prevalence of AF in patients with ESUS using continuous cardiac monitoring by implantable loop recorder (ILR) with daily remote interrogation over a period of 3 years and its clinical consequences, including recurrent stroke. Methods: In consecutive patients with an ESUS diagnosis after complete work-up, an ILR was implanted and followed by daily remote monitoring until AF was detected or a follow-up of at least 3 years was completed. Additionally the ILR was interrogated in-hospital in 6-month intervals. Results: A total of 123 patients (74 male, mean age 65±9 years) were enrolledand completed the 3 years study period. AF was detected in 51 patients (41.4%). In 42 of the 51 AF positive patients (82%) oral anticoagulation was established. Recurrent strokes occurred in 28 patients (23%) of this ESUS population, 11 of these patients (21%) being AF positive, 17 (23%) AF negative. Patients with AF were slightly older than patients without AF (63.1±8.8 versus 67.5±9.6 years, p=0.12). Other parameters such as CHA2DS2-VASc score, infarct localization, micro- and macroangiopathy, carotid- or aortic plaques or stroke recurrence were not significantly different between groups. Conclusions: In ESUS patients, early implantation of an ILR with cardiac monitoring and remote transmission over a 3-year period detects AF in 41.4 % and results in oral anticoagulation in 82% of these patients

Hardware challenges with an anticoagulation strategy guided by detection of atrial fibrillation by an implantable loop recorder

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Mittal ◽  
D Brenner ◽  
S Oliveros ◽  
A Bhatt ◽  
M Preminger ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Data Transmission ◽  
Data Transfer ◽  
Implantable Loop Recorder ◽  
Loop Recorder ◽  
Bedside Monitor ◽  
Pill In The Pocket ◽  
Fundamental Requirement ◽  
Ecg Data ◽  
Clinical Strategy

Abstract Background A “pill-in-the-pocket” anticoagulation strategy, guided by ECG data from an implantable loop recorder (ILR), has been advocated as a clinical strategy. However, a fundamental requirement is the ability to reliably obtain daily ECG data from patients. Objective To determine the reliability of daily ECG data transfer from ILRs. Methods We evaluated patients implanted with an ILR in whom we sought to withhold oral anticoagulation (OAC) unless atrial fibrillation (AF) was detected. The ILR transmits data nightly to a bedside monitor. Once received, the data are sent to a central server. Over the course of a month, we tracked for each patient whether ECG data were received by the server. Results The study included 170 AF patients with an ILR where we planned to withhold OAC unless AF was documented. Daily ECG data were automatically transmitted and retrievable in only 36 (21%) patients. Two (1%) pts had not a single day of connectivity, 6 (4%) pts were connected <7 days, and 16 (9%) pts were connected <14 days. Wireless connectivity was lost for >48 hours in 89 (52%) patients (Figure). Most patients experienced multiple reasons for data transmission failure within the month. Conclusions To determine whether an ILR guided OAC strategy is feasible, reliable daily transmission of ECG data is a fundamental prerequisite. Current technology facilitated daily ECG data transfer in only 1/5 of patients. In the remaining, there was either extended loss of connectivity or no connectivity at all. A “pill-in-the-pocket” anticoagulation approach is currently difficult given existing hardware limitations. Funding Acknowledgement Type of funding source: None

scholarly journals Predictors of Development of Atrial Fibrillation in Patients With Embolic Stroke Of Undetermined Source: An Analysis of the RE-SPECT ESUS Trial

Circulation ◽  
2021 ◽  
Author(s):  
Maria Cecilia Bahit ◽  
Ralph L. Sacco ◽  
J. Donald Easton ◽  
Juliane Meyerhoff ◽  
Lisa Cronin ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Body Mass Index ◽  
Body Mass ◽  
Recurrent Stroke ◽  
Controlled Trial ◽  
Clinical Care ◽  
Important Variable ◽  
Older Age ◽  
Embolic Stroke ◽  
Cardiac Monitoring

Background: A proportion of patients with embolic stroke of undetermined source (ESUS) have silent atrial fibrillation (AF) or develop AF after the initial evaluation. Better understanding of risk for development of AF is critical to implement optimal monitoring strategies with the goal of preventing recurrent stroke due to underlying AF. The RE-SPECT ESUS trial provides an opportunity to assess predictors for developing AF and associated recurrent stroke. Methods: RE-SPECT ESUS was a randomized, controlled trial (564 sites, 42 countries) assessing dabigatran versus aspirin for the prevention of recurrent stroke in patients with ESUS. Of 5390 patients enrolled and followed for a median of 19 months, 403 (7.5%) were found to develop AF reported as an adverse event or using cardiac monitoring per standard clinical care. Univariable and multivariable regression analyses were performed to define predictors of AF. Results: In the multivariable model, older age (odds ratio [OR] for 10-year increase 1.99 [1.78-2.23]; P<0.001), hypertension (1.36 [1.03-1.79]; P=0.0304), diabetes (OR 0.74 [0.56-0.96]; P=0.022), and body mass index (OR for 5-unit increase 1.29 [1.16-1.43]; P<0.001) were independent predictors of AF during the study. In a sensitivity analysis restricted to 1117 patients with baseline N-terminal prohormone of brain natriuretic peptide (NT-proBNP) measurements, only older age and higher NT-proBNP were significant independent predictors of AF. Performances of several published predictive models were assessed, including the HAVOC and CHA2DS2-VASc scores, and higher scores were associated with higher rates of developing AF. Conclusions: Besides age as the most important variable, several other factors, including hypertension, higher body mass index, and lack of diabetes, are independent predictors of AF after ESUS. When baseline NT-proBNP was available, only older age and elevation of this biomarker were predictive of subsequent AF. Understanding who is at higher risk of developing AF will assist in identifying patients who may benefit from more intense, long-term cardiac monitoring.

scholarly journals Efficacy of the Stand-Alone Cox-Maze IV Procedure in Patients with Longstanding Persistent Atrial Fibrillation

2021 ◽  
Author(s):  
Martha McGilvray ◽  
Nadia Bakir ◽  
Meghan Kelly ◽  
Samuel Perez ◽  
Laurie Sinn ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Persistent Atrial Fibrillation ◽  
Implantable Loop Recorder ◽  
Atrial Tachyarrhythmia ◽  
Loop Recorder ◽  
Factors Associated ◽  
Holter Monitor ◽  
Long Duration ◽  
Prolonged Monitoring

Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and results in significant morbidity and mortality. The Cox-Maze IV procedure (CMP-IV) has been shown to have excellent efficacy in returning patients to sinus rhythm, but there have been few reports of late follow-up in sizable cohorts of patients with longstanding persistent AF, the most difficult type of AF to treat. Methods & Results: Between May 2003 and March 2020, 174 consecutive patients underwent a stand-alone CMP-IV for longstanding persistent AF. Rhythm outcome was assessed postoperatively for up to 10 years, primarily via prolonged monitoring (Holter monitor, pacemaker interrogation, or implantable loop recorder). Fine-Gray regression was used to investigate factors associated with atrial tachyarrhythmia (ATA) recurrence, with death as a competing risk. Median duration of preoperative AF was 7.8 years (interquartile range [IQR] 4.0-12.0 years), with 71% (124/174) having failed at least one prior catheter-based ablation. There were no 30-day mortalities. Freedom from ATAs was 94% (120/128), 83% (53/64), and 88% (35/40) at 1, 5, and 7 years, respectively. On regression analysis, preoperative AF duration and early postoperative ATAs were associated with late ATAs recurrence. Conclusion: Despite the majority of patients having a long-duration of preoperative AF and having failed at least one catheter-based ablation, the stand-alone CMP-IV had excellent late efficacy in patients with longstanding persistent AF, with low morbidity and no mortality. We recommend consideration of stand-alone CMP-IV for patients with longstanding persistent AF who have failed or are poor candidates for catheter ablation.

Analysis of atrial fibrillatory rate during spontaneous episodes of atrial fibrillation in humans using implantable loop recorder electrocardiogram

2012 ◽  
Vol 45 (6) ◽  
pp. 723-726 ◽  
Author(s):  
Pyotr G. Platonov ◽  
Martin Stridh ◽  
Mirko de Melis ◽  
Lubos Urban ◽  
Jonas Carlson ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Implantable Loop Recorder ◽  
Loop Recorder
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