Comprehensive Evaluation of Rhythm Monitoring Strategies in Screening for Atrial Fibrillation

Background: Various non-invasive intermittent rhythm monitoring strategies have been used to assess arrhythmia recurrences in trials of atrial fibrillation (AF) ablation. We determined whether a frequency and duration of non-invasive rhythm monitoring could be identified that accurately detects arrhythmia recurrences and approximates the AF burden derived from continuous monitoring using an implantable cardiac monitor (ICM). Methods: The rhythm history of 346 patients enrolled in the CIRCA-DOSE trial was reconstructed. Using computer simulations, we evaluated event-free survival, sensitivity, negative predictive value, and AF burden of a range of non-invasive monitoring strategies, including those used in contemporary AF ablation trials. Results: A total of 126,290 monitoring days were included in the analysis. At 12 months, 164 patients experienced atrial arrhythmia recurrence as documented by the ICM (1-year event-free survival 52.6%). Most non-invasive monitoring strategies used in AF ablation trials had poor sensitivity for detecting arrhythmia recurrence. Sensitivity increased with the intensity of monitoring, with serial (3) short-duration monitors (24-/48-hour ECG monitors) missing a substantial proportion of recurrences (sensitivity 15.8% [95% confidence interval (CI) 8.9-20.7%] and 24.5% [95% CI 16.2-30.6%], respectively). Serial longer-term monitors (14-day ECG monitors) more closely approximated the gold-standard ICM (sensitivity 64.6% [95% CI 53.6-74.3%]). AF burden derived from short-duration monitors significantly over-estimated the true AF burden in patients with recurrences. Increasing monitoring duration resulted in improved correlation and concordance between non-invasive estimates of the invasive AF burden (R2 = 0.85 and interclass correlation coefficient = 0.91 for serial [3] 14-day ECG monitors vs ICM). Conclusions: Detection of arrhythmia recurrence following ablation is highly sensitive to the monitoring strategy employed, between-trial discrepancies in outcomes may reflect different monitoring protocols. Based on measures of agreement, serial long-term (7-14 day) intermittent monitors accumulating at least 28 days of annual monitoring provide estimates of AF burden comparable to ICM. However, ICMs outperform intermittent monitoring for arrhythmia detection, and should be considered the gold standard for clinical trials.

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Rhythm monitoring strategies in patients at high risk for atrial fibrillation and stroke: A comparative analysis from the REVEAL AF study

American Heart Journal ◽

10.1016/j.ahj.2019.07.016 ◽

2020 ◽

Vol 219 ◽

pp. 128-136 ◽

Cited By ~ 2

Author(s):

James A. Reiffel ◽

Atul Verma ◽

Peter R. Kowey ◽

Jonathan L. Halperin ◽

Bernard J. Gersh ◽

...

Keyword(s):

Atrial Fibrillation ◽

Comparative Analysis ◽

High Risk ◽

Monitoring Strategies ◽

Rhythm Monitoring

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Rhythm monitoring strategies for atrial fibrillation detection in patients with cryptogenic stroke: A systematic review and meta-analysis

IJC Heart & Vasculature ◽

10.1016/j.ijcha.2021.100780 ◽

2021 ◽

Vol 34 ◽

pp. 100780

Author(s):

Jean Jacques Noubiap ◽

Thomas A. Agbaedeng ◽

Joseph Kamtchum-Tatuene ◽

John L. Fitzgerald ◽

Melissa E. Middeldorp ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Meta Analysis ◽

Cryptogenic Stroke ◽

Monitoring Strategies ◽

Rhythm Monitoring ◽

Atrial Fibrillation Detection

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Long-term rhythm monitoring with an implantable loop recorder in patients after the first clinical atrial fibrillation episode. Towards an individualized management

Minerva Cardioangiologica ◽

10.23736/s0026-4725.19.04883-7 ◽

2019 ◽

Vol 67 (2) ◽

Author(s):

Panteleimon E. Papakonstantinou ◽

Emmanuel N. Simantirakis

Keyword(s):

Atrial Fibrillation ◽

Implantable Loop Recorder ◽

Loop Recorder ◽

Atrial Fibrillation Episode ◽

Individualized Management ◽

Rhythm Monitoring

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Atrial fibrillation recurrence and spontaneous conversion to sinus rhythm after cardiac surgery: Insights from 426 patients with continuous rhythm monitoring

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.15126 ◽

2021 ◽

Author(s):

Efstratios I. Charitos ◽

Florian E. M. Herrmann ◽

Paul D. Ziegler

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Sinus Rhythm ◽

Atrial Fibrillation Recurrence ◽

Rhythm Monitoring ◽

Spontaneous Conversion

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On-Demand Mobile Health Infrastructure for Remote Rhythm Monitoring within a Wait-and-See Strategy for Recent-Onset Atrial Fibrillation: TeleWAS-AF

Cardiology ◽

10.1159/000514156 ◽

2021 ◽

pp. 1-5

Author(s):

Nikki A.H.A. Pluymaekers ◽

Rachel M.J. van der Velden ◽

Astrid N.L. Hermans ◽

Monika Gawalko ◽

Saskia Buskes ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Rate ◽

Mobile Health ◽

Treatment Decision ◽

Care Process ◽

Care Utilization ◽

Recent Onset ◽

On Demand ◽

Wait And See ◽

Rhythm Monitoring

Recently, we introduced the TeleCheck-AF approach, an on-demand mobile health (mHealth) infrastructure using app-based heart rate and rhythm monitoring for 7 days, to support long-term atrial fibrillation (AF) management through teleconsultation. Herein, we extend the mHealth approach to patients with recent-onset AF at the emergency department (ED). In the proposed TeleWAS-AF approach, on-demand heart rate and rhythm monitoring are used to support a wait-and-see strategy at the ED. All stable patients who present to the ED with recent-onset symptomatic AF and who are able to use mHealth solutions for heart rate and rhythm monitoring are eligible for this approach. Patients will receive both education on AF and instructions on the use of the mHealth technology before discharge from the ED. A case coordinator will subsequently check whether patients are able to activate the mHealth solution and to perform heart rate and rhythm measurements. Forty hours after AF onset, the first assessment teleconsultation with the physician will take place, determining the need for delayed cardioversion. After maximal 7 days of remote monitoring, a second assessment teleconsultation may occur, in which the rhythm can be reassessed and further treatment strategy can be discussed with the patients. This on-demand mHealth prescription increases patient involvement in the care process and treatment decision-making by encouraging self-management, while avoiding excess data-load requiring work-intensive and expensive data management. Implementation of the TeleWAS-AF approach may facilitate the management of AF in the ED and reduce the burden on the ED system, which enhances the capacity for health care utilization.

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Abstract WP232: Biomarkers of Atrial Cardiopathy and Atrial Fibrillation Detection on Mobile Continuous Outpatient Telemetry After Cryptogenic Stroke

Stroke ◽

10.1161/str.48.suppl_1.wp232 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Denise Sebasigari ◽

Alexander Merkler ◽

Guo Yang ◽

Benjamin Kummer ◽

Gino Gialdini ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Cryptogenic Stroke ◽

Heart Rhythm ◽

Population Based ◽

Embolic Stroke ◽

P Wave ◽

Left Atrial Diameter ◽

New Diagnosis ◽

Rhythm Monitoring

Background: In population-based studies, biomarkers of atrial dysfunction or “cardiopathy” have been shown to be associated with embolic stroke risk. However, it is unclear if this risk is mediated by undiagnosed paroxysmal atrial fibrillation or flutter (AF). We aim to determine whether atrial cardiopathy biomarkers predict atrial fibrillation on continuous heart-rhythm monitoring after embolic stroke of undetermined source (ESUS). Methods: This was a single-center retrospective study including all patients who met consensus criteria for ESUS and who underwent 30 days of ambulatory heart-rhythm monitoring looking for AF between Jan 1 st , 2013 and Dec 31 st , 2015. We reviewed medical records for clinical, radiographic, and cardiac variables. The primary outcome was new diagnosis of AF detected during heart-rhythm monitoring. The primary predictors were atrial biomarkers: left atrial diameter on echocardiography, P-wave terminal force in ECG lead V1 , and PR interval on ECG. Multiple logistic regression was used to assess the relationship between atrial biomarkers and AF detection. Results: Among 196 eligible patients, 23 (11.7%) were diagnosed with AF. In unadjusted analyses, patients with AF were older (72.4 vs. 61.4 years, p < 0.001) and had larger left atrial diameter (39.2 vs. 35.7 mm, p = 0.03). In a multivariable model including variables significant on univariate analyses, the only predictor of AF was age ≥ 60 years (odds ratio, 3.0; 95% CI, 1.06-8.5; p = 0.04). Atrial biomarkers were not associated with AF detection. Conclusion: Atrial biomarkers were not associated with AF after ESUS. This suggests that previously reported associations between these markers and stroke may reflect independent cardiac pathways leading to stroke. Prospective studies are needed to investigate these mechanisms and study anticoagulation versus antiplatelet treatment for secondary stroke prevention in patients with ESUS and atrial cardiopathy.

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