scholarly journals Three year incidence and duration of atrial fibrillation episodes among a large, real-world population of cryptogenic stroke patients with insertable cardiac monitors

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
P.D Ziegler ◽  
J.D Rogers ◽  
M Richards ◽  
A.J Nichols ◽  
S.W Ferreira ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Real World ◽  
Stroke Prevention ◽  
Detection Rate ◽  
Large Population ◽  
Cryptogenic Stroke ◽  
World Population ◽  
Median Frequency ◽  
Secondary Stroke Prevention

Abstract Background/Introduction The primary goal of monitoring for atrial fibrillation (AF) after cryptogenic stroke (CS) is secondary stroke prevention. Therefore, long-term monitoring of CS patients with insertable cardiac monitors (ICMs) is likely important to ensure appropriate secondary stroke prevention therapy, regardless of when AF is detected after the index event. However, long-term data on the incidence and duration of AF from real-world populations are sparse. Purpose To investigate the long-term incidence and duration of AF episodes in real-world clinical practice among a large population of patients with ICMs placed for AF detection following CS. Methods We included patients from a large device manufacturer's database who received an ICM for the purpose of AF detection following CS and were monitored for up to 3 years. All detected AF episodes (≥2 minutes) were adjudicated. We quantified the AF detection rate for various episode duration thresholds using Kaplan-Meier survival estimates, analyzed the maximum duration of AF episodes, and measured the time to initial AF detection. Results A total of 1247 patients (65.3±13.0 years, 53% male) were included and followed for 763±362 days. AF episodes (n=5456) were detected in 257 patients, resulting in a median frequency of 5 episodes [IQR 2–19] per patient. At 3 years, the AF detection rate for episodes ≥2 minutes was 24.2%. The AF detection rates at 3 years for episodes ≥6 minutes, ≥30 minutes, and ≥1 hour were 22.4%, 20.6%, and 19.1%, respectively. The median duration of the longest detected AF episode was 4.4 [IQR 1.2–13.9] hours and the median time to AF detection was 129 [IQR 45–354] days. Conclusion AF episodes were detected via ICMs in approximately one-quarter of CS patients within 3 years of follow-up. More than 75% of patients with AF detected had episodes lasting ≥1 hour and half had episodes lasting ≥4 hours. Detection of the first AF episode typically occurred beyond the range of conventional ambulatory monitors. Long-term surveillance of CS patients is likely important given the appreciable incidence, frequency, and duration of these AF episodes. Funding Acknowledgement Type of funding source: None

Abstract TMP40: Impact of Age on Atrial Fibrillation Detection among a Large, Real-World Population of Cryptogenic Stroke Patients with Insertable Cardiac Monitors

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Mark Richards ◽  
John D Rogers ◽  
Scott W Ferreira ◽  
Allan J Nichols ◽  
Jodi L Koehler ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Median Time ◽  
Real World ◽  
Detection Rate ◽  
Recurrent Stroke ◽  
Anticoagulation Therapy ◽  
Cryptogenic Stroke ◽  
World Population ◽  
Time To Detection ◽  
The Impact

Introduction: Detection of atrial fibrillation (AF) in patients with a cryptogenic stroke (CS) is critical for reducing the risk of recurrent stroke by enabling oral anticoagulation therapy. However, the impact of age on AF detection and the optimum duration of AF monitoring in patients following a CS is not well characterized. We investigated the impact of age on AF detection among a large, real-world cohort of unselected patients with an implantable cardiac monitor (ICM) placed following CS. Methods: Patients in the de-identified Medtronic Discovery™ Link database who received an ICM (Reveal LINQ™) for AF detection following CS were included and monitored for up to 182 days. All AF episodes were adjudicated. We compared the mean age between patients with vs. without AF detected and compared the median time to detection of the first AF episode between younger (age ≤65) and older (age >65) patients. Results: Among 1247 patients (mean age 65.3±13.0, 53% male) followed for 182 [IQR 182-182] days, 1521 AF episodes were detected in 147 patients and resulted in an AF detection rate of 12.2%. Patients with AF detected were significantly older than patients without AF detected (71.3±10.9 vs. 64.5±13.1 years, respectively; p<0.001). The median time to detection of the first AF episode was shorter for older vs. younger patients (43 [10-91] vs. 89 [29-127] days, respectively; p=0.016; Figure). Conclusion: Continuous monitoring of CS patients with an ICM resulted in an AF detection rate of 12.2% within the initial 6 months. Patients with AF detected were older and patients >65 years of age had shorter times to initial AF detection. However even among older patients, the majority of AF occurred outside the range of external monitoring devices and thus highlights the importance of long-term monitoring with ICMs in the management of CS patients.

Abstract 17109: Real World Assessment of Atrial Fibrillation and Other Arrhythmias After Cryptogenic Stroke

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Naga Venkata K Pothineni ◽  
Uyanga Batnyam ◽  
Jeffrey Arkles ◽  
John Bullinga ◽  
Brett L CUCCHIARA ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Trials ◽  
Real World ◽  
Cryptogenic Stroke ◽  
Premature Ventricular Contractions ◽  
Entire Cohort ◽  
Detection Algorithms ◽  
Term Monitoring

Introduction: Long-term monitoring for atrial fibrillation (AF) is recommended in patients, who have experienced a cryptogenic stroke (CS). Clinical trials have identified AF in ~30% of patients after 3 years of continuous monitoring with insertable cardiac monitors (ICMs). Hypothesis: In a real-world analysis from a large academic healthcare system, we sought to evaluate a CS population with ICMs and a) determine the yield of AF and subsequent initiation of anticoagulation; and b) identify the presence of other arrhythmias. Methods: We evaluated all CS patients who had received an ICM between October 2014 and April 2020. We manually reviewed all stored electrocardiograms that were automatically labeled as AF by the ICM and adjudicated them as either a) AF or b) other cardiac arrhythmia including premature atrial contractions (PAC), premature ventricular contractions (PVC), supraventricular tachycardia (SVT), or nonsustained ventricular tachycardia (NSVT). Results: A total of 84 CS patients with ICMs were included: 51% men, mean age 63 years, and mean CHA 2 DS 2 -VASc 4.1. Over a median follow-up duration of 15.7 months, there were 34 patients (40% of the cohort) who did not have any AF alerts. In the remaining 50 patients, there were 960 stored electrograms that were adjudicated. Only 154 recordings from 16 patients (19% of the entire cohort) were adjudicated as AF. Oral anticoagulation was initiated in all these patients with adjudicated AF. The remaining tracings, which had been automatically categorized by the ICM as AF alerts, represented 34 patients (40% of the cohort). These patients had other arrhythmias including frequent PACs or PVCs, SVT, or NSVT. Conclusions: Compared to clinical trials, our real-world assessment suggests that the yield of AF following CS is lower - approximately 20%. Our findings highlight the importance for reviewing device tracings given the high rates of false positive for AF. Further research to refine AF detection algorithms in ICMs is needed.

Abstract 13293: Detection of Atrial Fibrillation by Implantable Loop Recorders Following Cryptogenic Stroke: A Retrospective Study of Predictive Factors and Outcomes

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Sara Samaan ◽  
Beshoy Nazeer ◽  
Heidi Stoute ◽  
Wei Zhao ◽  
Susanna Szpunar ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Stroke Prevention ◽  
Multivariable Analysis ◽  
Cryptogenic Stroke ◽  
Embolic Stroke ◽  
Stroke Recurrence ◽  
Secondary Stroke Prevention ◽  
Recurrence Rates ◽  
Implantable Loop Recorders

Introduction: Cryptogenic strokes account for up to 40% of ischemic strokes. Atrial fibrillation (AF) is a known cause of ischemic stroke. Current data shows that occult AF can be detected by implantable devices at higher rates than conventional cardiac rhythm monitoring. There are, however, limited data available on risk factors and outcomes associated with AF detection by implantable loop recorders (ILRs). Objective: To investigate the risk factors and outcomes associated with occult AF detected by ILR in patients with cryptogenic stroke. Methods: We conducted a retrospective chart review of patients admitted with cryptogenic stroke at Ascension St John Hospital and Ascension Macomb-Oakland Hospital in Michigan who had ILRs placed from 1/1/2016 to 1/31/2020. Data were collected on demographics, comorbidities, treatment and outcomes. AF detection was defined as continuous AF for 30 seconds. Data were analyzed using Student’s t-test, the χ2 test and logistic regression. Results: We reviewed 172 patients, 52.3% male, 56.4% white, mean age 62.7 ± 13.6 years. The incidence of AF detection by ILR was 14% (24/172) over a mean follow-up of 12.75 ± 10.71 months. The mean duration of monitoring prior to AF detection was 4.5 months (range:1 day to 14 months). The median duration of AF was 6 minutes (range: 37.2 seconds to 11.3 hours). From univariable analysis, older age (p=0.03), male sex (p=0.09), embolic stroke pattern on imaging (p=0.06), and lack of AF symptoms (p=0.001) were associated with AF detection by ILR. From multivariable analysis, patients with detected AF were more likely to be older (OR=1.04, p=0.04), male (OR=3.6, p=0.03), asymptomatic (OR=6.3, p=0.01), and have an embolic stroke pattern on imaging (OR=3.3, p=0.04). 95.7% of patients with confirmed AF were started on anticoagulation for secondary stroke prevention. There was no difference in the incidence of stroke post-hospitalization between those with AF detection and those without (16% vs. 16.4%, p=0.96). Conclusions: In patients with cryptogenic stroke, age, gender, stroke pattern, and lack of AF symptoms are independent predictors of occult AF detection by ILR. Most patients with confirmed AF were started on anticoagulation for secondary stroke prevention and had low stroke recurrence rates.

scholarly journals Long-term detection of atrial fibrillation with insertable cardiac monitors in a real-world cryptogenic stroke population

2017 ◽  
Vol 244 ◽  
pp. 175-179 ◽  
Author(s):  
Paul D. Ziegler ◽  
John D. Rogers ◽  
Scott W. Ferreira ◽  
Allan J. Nichols ◽  
Mark Richards ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Real World ◽  
Cryptogenic Stroke ◽  
Stroke Population

scholarly journals Secondary Stroke Prevention Following Embolic Stroke of Unknown Source in the Absence of Documented Atrial Fibrillation: A Clinical Review

2021 ◽  
Author(s):  
Irum D. Kotadia ◽  
Iain Sim ◽  
Rahul Mukherjee ◽  
Daniel O’Hare ◽  
Amedeo Chiribiri ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Prevention ◽  
Structural Changes ◽  
Stroke Risk ◽  
Cryptogenic Stroke ◽  
Embolic Stroke ◽  
Stroke Recurrence ◽  
Secondary Stroke Prevention ◽  
Unknown Source ◽  
The Relationship

Abstract Approximately one‐third of ischemic strokes are classified as cryptogenic strokes. The risk of stroke recurrence in these patients is significantly elevated with up to one‐third of patients with cryptogenic stroke experiencing a further stroke within 10 years. While anticoagulation is the mainstay of treatment for secondary stroke prevention in the context of documented atrial fibrillation (AF), it is estimated that up to 25% of patients with cryptogenic stroke have undiagnosed AF. Furthermore, the historical acceptance of a causal relationship between AF and stroke has recently come under scrutiny, with evidence to suggest that embolic stroke risk may be elevated even in the absence of documented atrial fibrillation attributable to the presence of electrical and structural changes constituting an atrial cardiomyopathy. More recently, the term embolic stroke of unknown source has garnered increasing interest as a subset of patients with cryptogenic stroke in whom a minimum set of diagnostic investigations has been performed, and a nonlacunar infarct highly suspicious of embolic etiology is suspected but in the absence of an identifiable secondary cause of stroke. The ongoing ARCADIA (Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke) randomized trial and ATTICUS (Apixiban for Treatment of Embolic Stroke of Undetermined Source) study seek to further define this novel term. This review summarizes the relationship between AF, embolic stroke, and atrial cardiomyopathy and provides an overview of the clinical relevance of cardiac imaging, electrocardiographic, and serum biomarkers in the assessment of AF and secondary stroke risk. The implications of these findings on therapeutic considerations is considered and gaps in the literature identified as areas for future study in risk stratifying this cohort of patients.

scholarly journals MR-imaging pattern is not a predictor of occult atrial fibrillation in patients with cryptogenic stroke

2019 ◽  
Vol 266 (12) ◽  
pp. 3058-3064 ◽  
Author(s):  
C. Vollmuth ◽  
S. Stoesser ◽  
H. Neugebauer ◽  
A. Hansel ◽  
J. Dreyhaupt ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Mr Imaging ◽  
Detection Rate ◽  
Cryptogenic Stroke ◽  
Lesion Size ◽  
Lacunar Infarct ◽  
Stroke Patients ◽  
First Time

Abstract Background To date, insertable cardiac monitors (ICMs) are the most effective method for the detection of occult atrial fibrillation (AF) in cryptogenic stroke. The overall detection rate after 12 months, however, is low and ranges between 12.4 and 33.3%, even if clinical predictors are considered. Ischemic stroke patients due to cardiogenic embolism present with particular lesion patterns. In patients with cryptogenic stroke, MR-imaging pattern may be a valuable predictor for AF. Methods This is an MRI-based, retrospective, observational, comparative, single-center study of 104 patients who underwent ICM implantation after cryptogenic stroke. The findings were compared to a reference group with related stroke etiology, i.e., 166 patients with embolic stroke due to AF detected for the first time by long-term ECG. Lesion patterns were evaluated with regard to affected territories, distribution (cortical, lacunar, scattered), lesion volume, and lesion size (diameter of the lesion size > 20 mm). Results The MR-imaging analysis of acute ischemic lesions yielded no association between AF and lesion size or volume, arterial vessel distribution, or the number of affected territories. There was no significant difference between the cohorts regarding ischemic patterns (cortical lesions, scattered lesions, and lacunar infarcts). An important clinical inference of our findings is that 10% (2 of 20) of cases in the ICM group in whom AF was detected had a lacunar infarct pattern. Similar results were shown in cases of ischemic stroke patients with AF detected for the first time by long-term ECG, with 10.9% (16 of 147) of them showing lacunar infarcts. The analysis of chronic MRI lesions revealed no differences between the groups in the rate of chronic lesions, arterial vessel distribution, or the number of affected territories. Left atrial size (LA size) and the presence of atrial runs in long-term ECG were independently associated with AF. Conclusions In this MRI-based analysis of patients with cryptogenic stroke who had received ICM implantation, the detection rate of AF in patients with ICM was not related to the imaging pattern. In addition, the lacunar infarct pattern should not be an exclusion criterion for ICM insertion in patients with cryptogenic stroke. ICM insertion in patients with cryptogenic stroke should not be evaluated solely on the basis of reference to infarct patterns.

scholarly journals Real-World Experience with Insertable Cardiac Monitors to Find Atrial Fibrillation in Cryptogenic Stroke

2015 ◽  
Vol 40 (3-4) ◽  
pp. 175-181 ◽  
Author(s):  
Paul D. Ziegler ◽  
John D. Rogers ◽  
Scott W. Ferreira ◽  
Allan J. Nichols ◽  
Shantanu Sarkar ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Real World ◽  
Cryptogenic Stroke ◽  
Relative Increase ◽  
Guideline Recommendation ◽  
World Population ◽  
Current Guideline ◽  
Detection Rates ◽  
Cardiac Monitor ◽  
Kaplan Meier

Background: The characteristics of atrial fibrillation (AF) episodes in cryptogenic stroke patients have recently been explored in carefully selected patient populations. However, the incidence of AF among a large, real-world population of patients with an insertable cardiac monitor (ICM) placed for the detection of AF following a cryptogenic stroke has not been investigated. Methods: Patients in the de-identified Medtronic DiscoveryLink™ database who received an ICM (Reveal LINQ™) for the purpose of AF detection following a cryptogenic stroke were included. AF detection rates (episodes ≥2 min) were quantified using Kaplan-Meier survival estimates at 1 and 6 months and compared to the CRYSTAL AF study at 6 months. The time to AF detection and maximum duration of AF episodes were also analyzed. Results: A total of 1,247 patients (age 65.3 ± 13.0 years) were followed for 182 (IQR 182-182) days. A total of 1,521 AF episodes were detected in 147 patients, resulting in AF detection rates of 4.6 and 12.2% at 30 and 182 days, respectively, and representing a 37% relative increase over that reported in the CRYSTAL AF trial at 6 months. The median time to AF detection was 58 (IQR 11-101) days and the median duration of the longest detected AF episode was 3.4 (IQR 0.4-11.8) h. Conclusions: The real-world incidence of AF among patients being monitored with an ICM after a cryptogenic stroke validates the findings of the CRYSTAL AF trial and suggests that continuous cardiac rhythm monitoring for periods longer than the current guideline recommendation of 30 days may be warranted in the evaluation of patients with cryptogenic stroke.

P1024Catheter ablation is associated with reduced all-cause mortality in a real-world cohort of patients with atrial fibrillation and heart failure

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Samuel ◽  
M Abrahamowicz ◽  
J Joza ◽  
V Essebag ◽  
L Pilote
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Major Bleeding ◽  
Real World ◽  
Population Based ◽  
World Population ◽  
Risk Of Death ◽  
All Cause Mortality

Abstract Background Atrial fibrillation (AF) and heart failure (HF) are common co-existing conditions. Randomized trial data suggests a reduction in all-cause mortality with catheter ablation (CA) in selected patients, however, whether these results are replicable in a real-world population and persist in the long-term remains to be shown. Purpose To evaluate the long-term effectiveness of CA in AF-HF patients in reducing the incidence of: a) all-cause mortality b) HF hospitalizations, and c) major morbidities (stroke/transient ischemic attack (TIA) and major bleeding). Methods A population-based administrative cohort was created of AF-HF patients with government prescription coverage in Quebec, Canada (1999–2015). Patients who underwent CA (cases) were matched 1:2 to controls using risk-set sampling. Cases were matched on time in the cohort and frequency of hospitalizations. Measured time-invariant confounders were controlled for using inverse probability of treatment weighting (IPTW) and included age, sex, clinical characteristics, presence of cardiac implantable electronic devices, and medication use. Multivariable Cox models adjusted the association of CA with the outcomes for the time varying confounders of the presence of an implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT), anticoagulation use (warfarin or direct oral anticoagulation), and any antiarrhythmic (AAD) use during follow-up. For non-fatal outcomes, the competing risk of death was accounted for using the Lunn-McNeil approach. Results Of the 87,676 AF-HF patients, 298 underwent CA and were matched to 591 controls. After IPTW, the distribution of covariates was balanced between cases and controls [age 65.6±11.0 vs 61.6±11.6; women 24% vs 20%; CHA2DS2-Vasc score 3.2±2.3 vs 2.9±2.1; CA vs non-CA, respectively; standardized mean differences <0.1 for all]. Over a median follow-up of 3.3 (IQR 1.1–6.4) years, 19 (7.3%) of CA patients died compared to 144 (24.6%) non-CA patients. After weighting and adjustment, CA was associated with a statistically significant reduction in the incidence of all-cause mortality [adjusted HR 0.5 (95% CI 0.3–0.9)]. In addition, there was no statistically significant difference in the incidence of HF hospitalizations over the follow-up [CA: 22.5% vs non-CA: 27.1%; adjusted HR 0.9 (95% CI 0.6–1.2)]. The incidences of stroke/TIA (1.7% vs 6.8%) and major bleeding (1.7% vs 4.9%) for CA vs non-CA were not statistically different. Conclusion In a matched population-based AF-HF cohort, CA was associated with a reduced risk of all-cause mortality compared to patients who did not undergo CA. Although no difference in the risk of HF hospitalizations, stroke/TIA, and major bleeding was detected between CA and non-CA patients, larger studies are warranted. Acknowledgement/Funding Canadian Institute of Health Research; Fonds de recherché du Quebec-Santé, Clinical Research Scholar Award (V. Essebag) and Doctoral Award (M. Samuel)

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