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.

P1011Cryptogenic stoke and asymptomatic atrial fibrillation in a real world population: a single centre, implantable loop recorder study

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
M Faustino ◽  
V Di Stefano ◽  
R Franciotti ◽  
N Furia ◽  
E Di Girolamo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Real World ◽  
Cryptogenic Stroke ◽  
Daily Practice ◽  
World Population ◽  
Real World Data ◽  
Loop Recorder ◽  
Cardiac Monitor ◽  
Mean Time

Abstract Funding Acknowledgements None Background The incidence of atrial fibrillation (AF) in cryptogenic stroke (CS) patients has been studied in carefully controlled clinical trials, but real-world data are limited. Purpose Aim of this study was to investigated the incidence of AF in clinical practice among CS patients with an implantable cardiac monitor (ICM) recommended (IIA) for AF detection. Methods Patients with CS admitted to our Stroke Unit were included in the study. Patiens received an ICM and were monitored for up to 2 years for AF detection (in-hospital clinic and remote monitoring). All detected AF episodes (≥30 sec) were considered. Results From March 2016 to March 2019, 58 patients (mean age 68 ±12 years, 67% male) received an ICM to detect AF after a CS.  No patients were lost during follow-up. AF was detected in 23 patients (40% overall; AF group mean age 72 ± 11 years; 65% male) after a mean time of 6 months from ICM implantation (ranging from 2 days up to 2 years) and 8 months after CS (ranging from 1 month up to 2 years). In these AF patients anticoagulant treatment was prescribed, and no further stroke was reported. Conclusions AF episodes were detected via continuous monitoring with ICMs in 40% of implanted CS patients. AF after CS was asymptomatic and thus unlikely to be detected by strategies based on intermittent short-term recordings. Therefore, ICMs should be considered as part of daily practice in the evaluation of CS patients. Abstract Figure 1. Detection rate over time

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 78: Incidence of Atrial Fibrillation Among Patients with an Embolic Stroke of Undetermined Source

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Rod S Passman ◽  
Marilyn M Rymer ◽  
Shufeng Liu ◽  
Paul D Ziegler
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
Cryptogenic Stroke ◽  
Population Monitoring ◽  
Stroke Work ◽  
Stroke Event ◽  
Detection Rates ◽  
Kaplan Meier ◽  
Index Stroke ◽  
Prophylactic Use

Introduction: Trials are underway to evaluate the prophylactic use of novel oral anticoagulants (NOAC) in patients with embolic strokes of undetermined source (ESUS). It is uncertain whether the bleeding risks associated with prophylactic NOAC use will outweigh any stroke prevention benefit in ESUS patients who lack underlying atrial fibrillation (AF). Methods: We determined the proportion of patients in the CRYSTAL AF study who met ESUS trial criteria and had AF (≥2 minutes) detected within 3 years via an insertable cardiac monitor (ICM). Cryptogenic stroke patients ≥50 years old with a modified Rankin score ≤3 and no evidence of lacunar infarcts after an extensive stroke work up were included. Age ≥60 years and CHA 2 DS 2 VASc score ≥3 were required for patients whose index stroke occurred 3-6 months before randomization. We also compared AF detection rates between the ICM and standard monitoring arms using Kaplan-Meier estimates and computed the percentage of patients with AF detected within the initial 30 days of ICM monitoring. Results: Among the 441 patients enrolled in CRYSTAL AF, 246 (55.8%) met inclusion criteria for the ongoing ESUS trials. AF detection rates at 3 years reached 38.5% in the ICM arm vs. 2.7% in the control arm (HR 12.1 [3.7-39.3], p<0.0001, Figure). In contrast, AF detection rates at 30 days were only 6.7% and 0.8% in the ICM and control arm, respectively. Conclusions: Among the subset of CRYSTAL AF patients who met the ESUS trial criteria, >60% did not have AF detected via ICMs within 3 years of their index stroke event. Prophylactic NOAC use in the absence of AF may therefore increase bleeding risks without providing protection against AF-related stroke in the majority of ESUS patients. Furthermore, ICMs were superior to standard monitoring for AF detection in this ESUS population. Monitoring continuously for only the initial 30 days would have failed to identify AF in >80% of patients ultimately found to have AF via an ICM.

scholarly journals Cryptogenic stroke and atrial fibrillation in a real-world population: the role of insertable cardiac monitors

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Maria Vittoria De Angelis ◽  
Vincenzo Di Stefano ◽  
Raffaella Franciotti ◽  
Nanda Furia ◽  
Enrico Di Girolamo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Real World ◽  
Cryptogenic Stroke ◽  
World Population

scholarly journals Implantable cardiac monitor after cryptogenic stroke: atrial fibrillation detection and predictors

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
E Ebrille ◽  
C Amellone ◽  
M.T Lucciola ◽  
F Orlando ◽  
M Suppo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Multivariate Analysis ◽  
Risk Stratification ◽  
Median Time ◽  
Remote Monitoring ◽  
Cryptogenic Stroke ◽  
Screening Process ◽  
Cardiac Monitor ◽  
Implantable Cardiac Monitor

Abstract Objective The main objective of our study was to analyze the incidence and predictors of atrial fibrillation (AF) in patients with cryptogenic stroke (CS) who received an implantable cardiac monitor (ICM) at our Institution. Methods From November 2013 to October 2017, a total of 133 patients who had suffered a CS were implanted with an ICM after a thorough screening process. The median time between the thromboembolic event and ICM implantation was 64 days [IQ range: 16–111]. All implanted patients were followed with remote monitoring until the first detected episode of AF or up to December 2018. Every remote monitoring transmission and related electrograms were analyzed by the dedicated Electrophysiology Nursing team and confirmed by experienced Electrophysiologists. AF was defined by any episode lasting greater than or equal to 2 minutes. Results During a median follow-up of 14.8 months [IQ range: 3.0–31.2], AF was detected in 65 out of 133 patients (48.9%). The median time from ICM implantation and AF detection was 3.5 months [IQ range: 0.9–6.7]. The prevalence of AF was 22.6%, 34.4%, 40.8% and 48.3% at 3, 6, 12 and 24 months respectively. At the multivariate analysis, high premature atrial contractions (PAC) burden and left atrium (LA) dilation were the only independent predictors of AF detection (HR 2.82, 95% CI 1.64–4.83, p&lt;0.001 for PAC; HR 1.75, 95% CI 1.03–2.97, p=0.038 for LA dimension). Patients were dived into categories based on the probability of AF detection (low, intermediate and high risk) and a new risk stratification algorithm was implemented (Figure 1). Conclusion After a thorough screening process, AF detection in patients with CS and ILM was quite high. Having a high PAC burden and LA dilation predicted AF episodes at the multivariate analysis. A new risk stratification algorithm was developed. Figure 1 Funding Acknowledgement Type of funding source: None

Safety and Effectiveness of Dabigatran in Atrial Fibrillation in a Real-World Population

2013 ◽  
Vol 29 (10) ◽  
pp. S103
Author(s):  
M Pichette ◽  
A Dutilleul ◽  
L Stevens ◽  
N Noiseux ◽  
F Gobeil ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Real World ◽  
World Population

scholarly journals Infarct Topography and Detection of Atrial Fibrillation in Cryptogenic Stroke: Results from CRYSTAL AF

2015 ◽  
Vol 40 (1-2) ◽  
pp. 91-96 ◽  
Author(s):  
Richard A. Bernstein ◽  
Vincenzo Di Lazzaro ◽  
Marilyn M. Rymer ◽  
Rod S. Passman ◽  
Johannes Brachmann ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cox Regression ◽  
Brain Infarction ◽  
Cryptogenic Stroke ◽  
Monitoring Methods ◽  
Brain Images ◽  
Kaplan Meier ◽  
Imaging Characteristics ◽  
Hazard Ratios ◽  
Routine Monitoring

Background: Insertable cardiac monitors (ICM) have been shown to detect atrial fibrillation (AF) at a higher rate than routine monitoring methods in patients with cryptogenic stroke (CS). However, it is unknown whether there are topographic patterns of brain infarction in patients with CS that are particularly associated with underlying AF. If such patterns exist, these could be used to help decide whether or not CS patients would benefit from long-term monitoring with an ICM. Methods: In this retrospective analysis, a neuro-radiologist blinded to clinical details reviewed brain images from 212 patients with CS who were enrolled in the ICM arm of the CRYptogenic STroke And underLying AF (CRYSTAL AF) trial. Kaplan-Meier estimates were used to describe rates of AF detection at 12 months in patients with and without pre-specified imaging characteristics. Hazard ratios (HRs), 95% confidence intervals (CIs), and p values were calculated using Cox regression. Results: We did not find any pattern of acute brain infarction that was significantly associated with AF detection after CS. However, the presence of chronic brain infarctions (15.8 vs. 7.0%, HR 2.84, 95% CI 1.13-7.15, p = 0.02) or leukoaraiosis (18.2 vs. 7.9%, HR 2.94, 95% CI 1.28-6.71, p < 0.01) was associated with AF detection. There was a borderline significant association of AF detection with the presence of chronic territorial (defined as within the territory of a first or second degree branch of the circle of Willis) infarcts (20.9 vs. 10.0%, HR 2.37, 95% CI 0.98-5.72, p = 0.05). Conclusions: We found no evidence for an association between brain infarction pattern and AF detection using an ICM in patients with CS, although patients with coexisting chronic, as well as acute, brain infarcts had a higher rate of AF detection. Acute brain infarction topography does not reliably predict or exclude detection of underlying AF in patients with CS and should not be used to select patients for ICM after cryptogenic stroke.

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

2011 ◽  
Vol 2011 ◽  
pp. 1-5 ◽  
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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