Insertable cardiac monitors after cryptogenic stroke - a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation

Objective The present study aimed to investigate the effect of functional mitral regurgitation (FMR) on recurrence of paroxysmal atrial fibrillation (PAF) in patients undergoing radiofrequency catheter ablation. Methods This prospective cohort study comprised 107 patients with PAF. The patients were divided into the FMR and non-FMR groups. FMR was assessed by Doppler echocardiography before index ablation. All patients initially underwent circumferential pulmonary vein isolation (CPVI) and were followed up for 12 months after ablation. PAF, atrial tachycardia, or atrial flutter served as the endpoint indicator. Results The median duration of PAF was 24 (3–60) months. Binary logistic univariate and multivariate analyses showed that FMR was not a risk factor for recurrence of catheter ablation for PAF (hazard ratio=0.758, 95% confidence interval: 0.191–3.004; hazard ratio=0.665, 95% confidence interval: 0.134–3.300, respectively). Kaplan–Meier analysis showed no significant difference in the recurrence rate between the groups. Fifteen (15/107, 14%) cases of PAF were triggered by the pulmonary vein. Three (3/107, 2.8%) cases of PAF were triggered by the superior vena cava. Conclusions FMR is not an independent risk factor for predicting recurrence of catheter ablation for PAF. FMR does not affect patients undergoing radiofrequency catheter ablation for PAF.

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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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Detection of Subclinical Paroxysmal Atrial Fibrillation and Its Correlation with Candidate Genes in Patients with Cryptogenic Ischemic Stroke and TIA

Acta Medica Martiniana ◽

10.2478/acm-2021-0007 ◽

2021 ◽

Vol 21 (2) ◽

pp. 42-53

Author(s):

A Petrovicova ◽

E Kurca ◽

A Andrasova ◽

J Bernatova ◽

P Blasko ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Paroxysmal Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Preventive Treatment ◽

Correct Choice ◽

Control Group ◽

Nucleotide Polymorphisms ◽

Loop Recorder ◽

Ischemic Attack

Abstract Introduction: Cardioembolic etiology is assumed to be the most frequent cause of cryptogenic strokes. The detection of subclinical paroxysmal atrial fibrillation (AF) is important in the correct choice of preventive treatment. The aim of this prospective study was to detect the incidence of AF in patients with a cryptogenic stroke or transient ischemic attack (TIA) and to evaluate the association between the presence of AF and selected single-nucleotide polymorphisms (SNP). Methods: Patients with a cryptogenic stroke/ TIA (n=100) and a control group (n=15) of volunteers without significant cardiovascular disease were included in the study during the period of 2014 to 2019. To detect AF they underwent 12 months of ECG monitoring using an implanted loop recorder (ILR). Genotyping for SNPs rs10033464, rs2200733, rs225132, and rs2106261 was performed by a high resolution melting analysis. Results: We found AF to be present in 24 (24%) patients with a cryptogenic stroke/TIA, versus no subjects in the control group. The SNPs rs2106261, rs2200733, rs225132, and rs10033464 were not found to be associated with AF in our study (p=0.240; 1.000; 0.887; 0.589). However, a weak trend for a higher frequency of rs2106261 risk allele A homozygotes was observed in the patients with AF compared to the patients without AF (0.416 vs. 0.263, p=0.073). Homozygotes for allele A of rs2106261 were also present in a significantly higher frequency in AF patients compared to the controls (0.416 vs. 0.133, p = 0.012). Conclusion: In our study paroxysmal AF was a probable etiological factor in 24% of patients with cryptogenic ischemic stroke / TIA during the 12 months of monitoring. The homozygous allele A of rs2106261 was identified to be the possible genetic risk factor of AF, but this should be verified in larger cohorts. The study has been registered at www.clinicaltrials.gov, identifier NCT02216370.

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Prevalence of paroxysmal atrial fibrillation in patients with cerebrovascular stroke of undetermined etiology

QJM ◽

10.1093/qjmed/hcab090.026 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Mohammed Elnwagy ◽

Hossam Shokery ◽

Emad Effat ◽

Hayam El Damnhory

Keyword(s):

Atrial Fibrillation ◽

Paroxysmal Atrial Fibrillation ◽

Left Atrial ◽

Cryptogenic Stroke ◽

Holter Monitoring ◽

Ectopic Beat ◽

Unknown Etiology ◽

P Value ◽

Undetermined Etiology ◽

Cerebrovascular Stroke

Abstract Background cerebrovascular stroke is major cause of morbidity and disability. Many causes may contribute to its presence, however. Some patients have none of the identified risk factors, yet face the consequences of stroke or transit ischemic attack. This type of stroke known to be stroke of undetermined source or etiology. It has a high rate of recurrence due to the persistence of the unknown etiology. Paroxysmal atrial fibrillation remains the hidden bottom of an iceberg representing a major part of the causes of ischemic cerebrovascular stroke of undetermined etiology . Aim and Objectives: to determine the prevalence of subclinical atrial fibrillation in patients with ischemic cerebrovascular stroke of undetermined etiology in a population in Egypt by 48h holter monitoring. Patients and Methods Patients diagnosed with acute cerebrovascular stroke of undetermined etiology at the neurology department of Ain Shams university hospitals underwent 48 hours holter monitoring within the first week of the insulting event. Results This study included 50 patients with cryptogenic stroke (CS) who underwent 48 hours holter monitoring. The patients' ages ranged between 22 and 77 years old (mean age 48.46 ± 12.74years). This study included 34 males and 16 females. Their body mass index BMI ranges from 21-35 kg/m2, with mean BMI of 24.78 ± 2.99 kg/m2. Their left atrial diameter ranges from 26-47mm, with mean diameter of 36.08 ± 5.23mm .Eight out of fifty patients newly diagnosed with subclinical atrial fibrillation with prevalence of 16%. There was statistically significant association between the atrial fibrillation (AF) and both age (p value, 009) and left atrial (LA) diameter (p value, 001) .There was an associated finding that need further investigation about the significant association between the ventricular ectopic beat VEB burden and the presence of AF or stroke. Conclusion The prevalence of paroxysmal atrial fibrillation among the population of ischemic stroke of undetermined etiology in a population in Egypt is close to worldwide percentage and the recent met analysis studies of 11%.

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Paroxysmal Atrial Fibrillation in Cryptogenic Stroke Patients With Major-Vessel Occlusion

Frontiers in Neurology ◽

10.3389/fneur.2020.580572 ◽

2020 ◽

Vol 11 ◽

Author(s):

Ryosuke Doijiri ◽

Hiroshi Yamagami ◽

Masafumi Morimoto ◽

Tomonori Iwata ◽

Tetsuya Hashimoto ◽

...

Keyword(s):

Atrial Fibrillation ◽

Paroxysmal Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Stroke Patients ◽

Vessel Occlusion ◽

Major Vessel

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Paroxysmal Atrial Fibrillation: An Independent Risk Factor for Prothrombotic Conditions

Journal of Atrial Fibrillation ◽

10.4022/jafib.2297 ◽

2020 ◽

Vol 13 (2) ◽

Author(s):

Dhanunjaya Lakkireddy

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Paroxysmal Atrial Fibrillation ◽

Independent Risk Factor

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

European Heart Journal ◽

10.1093/ehjci/ehaa946.0394 ◽

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

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

Stroke ◽

10.1161/str.47.suppl_1.tmp40 ◽

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.

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