Abstract 13915: Atrial Fibrillation Begets Atrial Fibrillation in Cryptogenic Stroke Patients: Results from the Crystal-AF Trial

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Rod S Passman ◽  
Jodi L Koehler ◽  
Paul D Ziegler
Keyword(s):  
Atrial Fibrillation ◽  
Cryptogenic Stroke ◽  
Secondary Stroke Prevention ◽  
Stroke Patients ◽  
Cardiac Monitor ◽  
Long Duration ◽  
Episode Duration ◽  
Duration Information ◽  
The Impact ◽  
Insertable Cardiac Monitor

Introduction: Initial episodes of atrial fibrillation (AF) detected following a cryptogenic stroke (CS) may be brief in duration and the clinical relevance of such episodes is uncertain. Hypothesis: We investigated whether an initial brief episode of AF was predictive of subsequent long duration AF episodes in CS patients (pts) with an insertable cardiac monitor (ICM). Methods: CS pts (n=208, age 61.6±11.3 years, 66% male) randomized to the ICM arm of the CRYSTAL-AF study and inserted with a device (Reveal® XT) were followed for 21±9 months. AF episodes (>30 seconds) were independently adjudicated and the first adjudicated AF episode was classified as brief (<1 hour) or long (≥1 hour). The incidence of subsequent long duration AF episodes among pts with an initially brief episode was computed. The impact of episode duration on prescription of oral anticoagulation (OAC) therapy was also assessed. Results: Among 36 pts with an adjudicated AF episode for which duration information was available, the initial episode was classified as brief in 18 (50%) pts and long in 18 (50%) pts. Among those with initially brief episodes, 10 (56%) experienced only subsequent brief episodes while 8 (44%) went on to experience at least one long AF episode. The median time between the initial brief episode and first long AF episode was 75 days [interquartile range: 27-624 days]. OAC was prescribed in 7/10 pts (70%) with only brief AF episodes compared to 26/26 pts (100%) with at least one long episode of AF (p=0.017). Conclusion: Initial AF episodes in pts with CS are equally likely to be of short or long duration. However, nearly half of CS pts with initially brief episodes of AF subsequently have long duration episodes detected much later via prolonged monitoring with ICMs. Therefore, early detection of brief AF episodes may merit more rigorous monitoring of AF with ICMs since physicians were significantly more likely to prescribe OAC for secondary stroke prevention in response to longer duration episodes.

012 Cost-effectiveness of long-term continuous monitoring with an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke: an australian payer perspective

2018 ◽  
Vol 89 (6) ◽  
pp. A6.2-A6 ◽  
Author(s):  
Vincent Thijs ◽  
Carmel Guarnieri ◽  
Koji Makino ◽  
Dominic Tilden ◽  
Marianne Huynh
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulation ◽  
Continuous Monitoring ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
Cost Effective ◽  
Cardiac Monitor ◽  
Payer Perspective ◽  
Insertable Cardiac Monitor

IntroductionDetection of atrial fibrillation (AF) is required to initiate oral anticoagulation (OAC) after cryptogenic stroke. However, paroxysmal AF can be difficult to diagnose with short term cardiac monitoring. Taking an Australian payer perspective, we evaluated whether long-term continuous monitoring with an insertable cardiac monitor (ICM) is cost-effective for preventing recurrent stroke in patients with cryptogenic stroke.MethodsA lifetime Markov model was developed to simulate the follow-up of patients, comparing long-term continuous monitoring with an ICM to monitoring by conventional care. We used a linked evidence approach to estimate the rates of recurrent stroke when AF detection leads to initiation of oral anticoagulation, as detected using ICM during the lifetime of the device, or as detected using usual care. All diagnostic and patient management costs were modelled. Other model inputs were determined by literature review. Probabilistic sensitivity analysis (PSA) was undertaken to explore the effect of parameter uncertainty according to CHADS2 score and oral anticoagulation treatment effect.ResultsIn the base-case analysis, the model predicted an incremental cost-effectiveness ratio (ICER) of A$29 570 per quality adjusted life year (QALY). Amongst CHADS2sub-groups analyses, the ICER ranged from A$26,342/QALY (CHADS2=6) to A$42,967/QALY (CHADS2=2). PSA suggested that the probabilities of ICM strategy being cost-effective were 53.4% and 78.7%, at thresholds of $30 000 (highly cost-effective) and $50 000 per QALY (cost-effective), respectively.ConclusionLong-term continuous monitoring with ICM is a cost-effective intervention to prevent recurrent stroke in patients following cryptogenic stroke in the Australian context.

Abstract 14: Use of an Insertable Cardiac Monitor to Detect Atrial Fibrillation is Cost Effective in Patients with Cryptogenic Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Alex Diamantopoulos ◽  
Laura Sawyer ◽  
Dilpreet Sungher ◽  
Gregory Lip ◽  
Klaus Witte ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
Cost Effective ◽  
Cardiac Monitor ◽  
The Uk ◽  
Insertable Cardiac Monitor

Introduction: The cause of ischemic stroke remains uncertain (cryptogenic stroke) in 20-40% of cases despite conventional diagnostic tests. Documentation of atrial fibrillation (AF) is required to initiate anticoagulant therapy to reduce recurrent stroke risk, however, the paroxysmal and asymptomatic nature of AF means it is often not detected with traditional monitoring techniques. We assessed the hypothesis that detecting AF via continuous long-term monitoring with an insertable cardiac monitor (ICM) is cost effective for preventing recurrent stroke in cryptogenic stroke patients, in comparison to Standard of Care (SoC). Methods: A randomized controlled trial reported a nine-fold increase in AF detection with an ICM (Reveal XT, Medtronic) compared to SoC over 3 years follow-up, after exclusion of patients with evidence of AF from initial tests. A lifetime Markov model was developed which uses trial data to estimate cost effectiveness of ICM from a U.K. NHS perspective. The CRYSTAL AF study provided AF detection rates, ICM implant complications, resource use and baseline quality of life. Safety and efficacy data for specific non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin were sourced from literature to estimate stroke and bleeding risks. Other quality of life and cost data were sourced mainly from the UK OXVASC study. All costs and benefits were discounted at 3.5% and scenario analyses (CHADS2 score) and probabilistic sensitivity analyses (PSA) were conducted. Results: ICM was associated with fewer recurrent strokes and increased Quality Adjusted Life Years (QALYs) compared to SoC. Stroke-related costs were reduced in the ICM arm, however, overall costs did remain higher than SoC. The incremental cost-effectiveness ratio (ICER) was below a £30,000 per QALY gained willingness-to-pay threshold. Sensitivity analysis indicated that the ICER increased in patients with lower CHADS2 scores, however, it remained below the threshold. Conclusion: AF detection with ICM increases linearly over its 3 year life, identifying AF in nine-fold more patients than SoC. ICM appears to be a cost-effective diagnostic tool for the prevention of recurrent stroke in patients with cryptogenic stroke in the UK and countries with similar healthcare systems.

Cost-effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke

2016 ◽  
Vol 11 (3) ◽  
pp. 302-312 ◽  
Author(s):  
Alex Diamantopoulos ◽  
Laura M. Sawyer ◽  
Gregory YH Lip ◽  
Klaus K Witte ◽  
Matthew R Reynolds ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cost Effectiveness ◽  
Cryptogenic Stroke ◽  
Cardiac Monitor ◽  
Insertable Cardiac Monitor

scholarly journals Atrial fibrillation burden, episode duration and frequency in relation to quality of life in patients with implantable cardiac monitor

2021 ◽  
Vol 34 ◽  
pp. 100791
Author(s):  
Victoria Jansson ◽  
Lennart Bergfeldt ◽  
Jonas Schwieler ◽  
Göran Kennebäck ◽  
Aigars Rubulis ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Atrial Fibrillation ◽  
Cardiac Monitor ◽  
Episode Duration ◽  
Atrial Fibrillation Burden ◽  
Implantable Cardiac Monitor

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

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