NEWLY DETECTED PAROXYSMAL ATRIAL FIBRILLATION AFTER TIA AND ISCHAEMIC STROKE ON CARDIAC MONITORING: SYSTEMATIC REVIEW AND META–ANALYSIS IN RELATION TO DURATION OF RECORDING

Objective:To identify clinical, ECG and blood-based biomarkers associated with atrial fibrillation (AF) detection after ischaemic stroke or transient ischaemic attack (TIA) that could help inform patient selection for cardiac monitoring.Methods:We performed a systematic review and meta-analysis and searched electronic databases for cohort studies from 15/01/2000-15/01/2020. The outcome was AF ≥30 seconds within one year after ischaemic stroke/TIA. We used random effects models to create summary estimates of risk. Risk of bias was assessed using the Quality in Prognostic Studies tool. PROSPERO registration: CRD42020168307.Results:We identified 8503 studies, selected 34 studies and assessed 69 variables (42 clinical, 20 ECG and seven blood-based biomarkers). The studies included 11569 participants and AF was detected in 1478 people (12.8%). Overall, risk of bias was moderate. Variables associated with increased likelihood of AF detection are older age (OR 3.26, 95%CI 2.35-4.54), female sex (OR 1.47, 95%CI 1.23-1.77), a history of heart failure (OR 2.56, 95%CI 1.87-3.49), hypertension (OR 1.42, 95%CI 1.15-1.75) or ischaemic heart disease (OR 1.80, 95%CI 1.34-2.42), higher modified Rankin Scale (OR 6.13, 95%CI 2.93-12.84) or National Institutes of Health Stroke Scale score (OR 2.50, 95%CI 1.64-3.81), no significant carotid/intracranial artery stenosis (OR 3.23, 95%CI 1.14-9.11), no tobacco use (OR 1.93, 95%CI 1.48-2.51), statin therapy (OR 2.07, 95%CI 1.14-3.73), stroke as index diagnosis (OR 1.59, 95%CI 1.17-2.18), systolic blood pressure (OR 1.61, 95%CI 1.16-2.22), intravenous thrombolysis treatment (OR 2.40, 95%CI 1.83-3.16), atrioventricular block (OR 2.12, 95%CI 1.08-4.17), left ventricular hypertrophy (OR 2.21, 95%CI 1.03-4.74), premature atrial contraction (OR 3.90, 95%CI 1.74-8.74), maximum P-wave duration (OR 3.19, 95%CI 1.40-7.25), PR interval (OR 2.32, 95%CI 1.11-4.83), P-wave dispersion (OR 7.79, 95%CI 4.16-14.61), P-wave index (OR 3.44, 95%CI 1.87-6.32), QTc interval (OR 3.68, 95%CI 1.63-8.28), brain natriuretic peptide (OR 13.73, 95%CI 3.31-57.07) and HDL-cholesterol (OR 1.49, 95%CI 1.17-1.88) concentrations. Variables associated with reduced likelihood are minimum P-wave duration (OR 0.53, 95%CI 0.29-0.98), LDL-cholesterol (OR 0.73, 95%CI 0.57-0.93) and triglyceride (OR 0.51, 95%CI 0.41-0.64) concentrations.Discussion:We have identified multi-modal biomarkers that could help guide patient selection for cardiac monitoring after ischaemic stroke/TIA. Their prognostic utility should be prospectively assessed with AF detection and recurrent stroke as outcomes.

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Abstract P667: Clinical Variables, Electrocardiogram Parameters and Blood Biomarkers Associated With Atrial Fibrillation Detection in the First Year After Ischaemic Stroke - A Systematic Review and Meta-Analysis

Stroke ◽

10.1161/str.52.suppl_1.p667 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Alan Cameron ◽

Huen Ki Cheng ◽

Ren Ping Lee ◽

Pouria Khashayar ◽

Mark Hall ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Ischaemic Stroke ◽

Odds Ratio ◽

Meta Analysis ◽

P Wave ◽

Cardiac Monitoring ◽

First Year ◽

Blood Biomarkers ◽

Clinical Variables

Introduction: Cardiac monitoring is performed to detect atrial fibrillation (AF) after stroke. Identifying patients at high or low risk of AF may allow cardiac monitoring approaches to be tailored on a more personalised basis. We performed a systematic review and meta-analysis to identify variables associated with AF detection after ischaemic stroke. Methods: We followed the Cochrane Collaboration Guidelines and retrieved 8503 studies. After screening, 35 studies were selected and 68 variables were assessed. We assessed 41 clinical variables, 20 ECG parameters and 7 blood biomarkers associated with AF detection >30 seconds duration in the first year after stroke. Comprehensive Meta-analysis software was used to generate an odds ratio and Forest plot for each variable. Studies were assessed for quality using the Quality in Prognostic Studies (QUIPS) tool. Results: The 35 studies included 12010 patients and AF was detected in 1551 patients (13%). Of the 68 variables assessed, 20 were associated with increased odds of AF, 5 were associated with reduced odds of AF and 43 were not associated with AF (Figure 1). The variables most strongly associated with AF detection (odds ratio >3.00) were older age, patients who received IV thrombolytic therapy, maximum P-wave duration, premature atrial complexes, P-wave dispersion, P-wave index, QTc interval and brain natriuretic peptide. Risk of bias was low in 3 studies, moderate in 24 studies and high in 8 studies. Conclusions: We have identified clinically applicable variables that can stratify the probability of AF detection after stroke. Our results will help guide more personalised approaches to cardiac monitoring for AF detection after stroke.

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Adjunctive ablation strategies improve the efficacy of pulmonary vein isolation in non-paroxysmal atrial fibrillation: a systematic review and meta-analysis

Expert Review of Cardiovascular Therapy ◽

10.1080/14779072.2017.1294064 ◽

2017 ◽

Vol 15 (3) ◽

pp. 227-235 ◽

Cited By ~ 4

Author(s):

Muhammad R. Afzal ◽

Anweshan Samanta ◽

Jawaria Chatta ◽

Brihh Ansari ◽

Sam Atherton ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Paroxysmal Atrial Fibrillation ◽

Meta Analysis

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Abstract WP229: Randomised Clinical Trial of Early Prolonged Ambulatory Cardiac monitoring After Stroke (EPACS): Interim Analysis

Stroke ◽

10.1161/str.48.suppl_1.wp229 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

James T Teo ◽

Judith Lenane ◽

Laszlo Sztriha ◽

Fong K Chan ◽

John Aeron-Thomas ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Paroxysmal Atrial Fibrillation ◽

Interim Analysis ◽

Controlled Trial ◽

Significant Proportion ◽

University Hospital ◽

Cardiac Monitoring ◽

Serious Adverse Events ◽

Index Event

Introduction: Cardioembolism in paroxysmal atrial fibrillation (PAF) is a preventable cause of ischaemic stroke or transient ischaemic attack (TIA), but the transient nature of PAF means that a short-duration Holter monitor misses a significant proportion of cases. Systems for recording beyond 3-7 days have significant limitations: event-triggered loop recorders are cumbersome while implanted loop recorders require a minor surgical procedure. There is a need for a patient-friendly long-duration cardiac monitoring system for stroke patients which can be performed without significant delay from the index event and with superior yield to Holter ECG’s. Methods: We conducted a pragmatic randomised controlled trial of cardiac monitoring after an ischaemic stroke or TIA to increase detection of paroxysmal atrial fibrillation (recruited within 72 hours of index event) using a wearable water-proof adhesive cardiac monitoring patch (Zio® Patch, iRhythm Technologies) that can be fitted immediately by the clinician early after the index event for up to 14 days or a standard Holter ECG. The trial aimed to recruit 120 patients across two locations - urban teaching hospital (Kings College Hospital, London) and suburban district hospital (Princess Royal University Hospital, Orpington). ISCRTN Registration 50253271. Results: In August 2016, the interim analysis detected PAF in 4/17 cases in the active arm and 0/16 cases in the control arm. The commonest arrhythmias detected were atrial tachyarrhythmias followed by PAF. Those in the control arm of Holter ECG’s had significant delays to initiate cardiac monitoring due to scheduling delays and patient non-attendance. There were no device-attributable serious adverse events. Further late-breaking results will be available in February 2017. Conclusion: The convenience of the Zio® Patch cardiac monitor substantially increased the uptake and efficiency of cardiac monitoring early after ischaemic strokes and TIA.

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The Short and Long-Term Efficacy of Pulmonary Vein Isolation as a Sole Treatment Strategy for Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis

Current Cardiology Reviews ◽

10.2174/1573403x13666170117125124 ◽

2017 ◽

Vol 13 (3) ◽

Cited By ~ 10

Author(s):

Zsuzsanna Kis ◽

Taulant Muka ◽

Oscar H. Franco ◽

Wichor M. Bramer ◽

Lennart J. De Vries ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Paroxysmal Atrial Fibrillation ◽

Treatment Strategy ◽

Meta Analysis ◽

Term Efficacy ◽

Short And Long Term

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Duration of Implantable Cardiac Monitoring and Detection of Atrial Fibrillation in Ischemic Stroke Patients: A Systematic Review and Meta-Analysis

Journal of Stroke ◽

10.5853/jos.2019.01067 ◽

2019 ◽

Vol 21 (3) ◽

pp. 302-311 ◽

Cited By ~ 8

Author(s):

Georgios Tsivgoulis ◽

Aristeidis H. Katsanos ◽

Martin Köhrmann ◽

Valeria Caso ◽

Fabienne Perren ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Ischemic Stroke ◽

Meta Analysis ◽

Cardiac Monitoring ◽

Stroke Patients

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Direct oral factor Xa inhibitors for the prevention of non-central nervous systemic embolism patients with non-valvular atrial fibrillation - a systematic review and meta-analysis

VASA ◽

10.1024/0301-1526/a000540 ◽

2016 ◽

Vol 45 (4) ◽

pp. 293-298

Author(s):

Victoria Gandara ◽

Fernando Vazquez ◽

Esteban Gandara

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Ischaemic Stroke ◽

Vitamin K ◽

Meta Analysis ◽

Factor Xa ◽

Factor Xa Inhibitors ◽

Secondary Outcome ◽

Controlled Trials ◽

Systemic Embolism

Abstract. Background: The aim of this systematic review and meta-analysis was to evaluate the efficacy of direct oral factor Xa inhibitors for preventing non-central nervous systemic embolism in patients with non-valvular atrial fibrillation. Methods: We conducted a systematic review of the following databases: Ovid Medline, Europubmed, Embase, and the Cochrane Central Register of Controlled Trials, from July 1st 1990 to April 1st, 2015. Randomised controlled trials were included if they reported the outcomes of patients with non-valvular atrial fibrillation treated with a direct oral factor Xa inhibitors compared to a vitamin K antagonist. The primary outcome was objectively confirmed as non-central nervous systemic embolism and ischaemic stroke was the secondary outcome. The random-effects model odds ratio was used as the outcome measure. Results: Our initial search identified 987 relevant articles, of which three satisfied our inclusion criteria and were included. Compared to vitamin K antagonists targeting an INR between 2 and 3, direct oral factor Xa inhibitors alone did not reduce the incidence of non-central nervous systemic embolism [OR 0.63 (95 % CI 0.30 - 1.35)] or ischaemic stroke [OR 1.06 (95 % CI 0.86 - 1.32)]. Conclusions: As a drug class, direct oral factor Xa inhibitors do not reduce the incidence of non-central nervous systemic embolism (or ischaemic stroke) in patients with non-valvular atrial fibrillation. Selecting drugs for the prevention of non-central nervous systemic embolism in patients with non-valvular atrial fibrillation should be based on individual drug efficacy data, rather than class data.

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