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

Stroke ◽  
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.

scholarly journals 319 Appropriate Duration of Extended Cardiac Monitoring for Atrial Fibrillation in Cryptogenic Stroke

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Kate Donlon ◽  
Robert Murphy ◽  
Edel Mannion ◽  
Ruairi Waters
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Ischaemic Stroke ◽  
Paroxysmal Atrial Fibrillation ◽  
Cryptogenic Stroke ◽  
Cardiac Monitoring ◽  
Loop Recorder ◽  
External Loop ◽  
The Mean ◽  
Time To Detection

Abstract Background Strokes due to cardio embolism are generally more severe and prone to early and long term recurrence. All forms of anticoagulant therapy are associated with a two thirds risk reduction in acute ischaemic stroke associated with atrial fibrillation. Establishing a diagnosis of paroxysmal atrial fibrillation can be a challenging one. Our study will attempt to answer the question as to what duration of extended cardiac monitoring is required when screening for atrial fibrillation in cryptogenic stroke. Methods We examined the time of atrial fibrillation initial diagnosis in 50 patients with an original working diagnosis of cryptogenic stroke but later have atrial fibrillation confirmed on extended monitoring. All patients wore the external loop recorder from 1 day to 3 weeks’ duration. On return of the device, data from the external loop recorder was downloaded, and reviewed by a consultant cardiologist. The total duration of monitoring using the external loop recorder was recorded. The time to first episode of algorithm detected atrial fibrillation was recorded. Results The mean duration of extended cardiac monitoring using the external loop recorder was 120.1days By seven days, atrial fibrillation had been detected in 94% of patients. By 72 hours, atrial fibrillation had been detected in 78% of patients. The mean age of participants was 58.3 years. 54.4% were female. The mean time to detection of atrial fibrillation was 52.9 hours. The median time to detection of atrial fibrillation was 34.2 hours. Conclusion External loop recorders present an opportunity for detection of paroxysmal atrial fibrillation in high risk individuals. Our study shows the feasibility and accuracy of a screening duration of seven days in the high risk post ischaemic stroke population. A one week screening timeframe allows us to screen twice as many patients for paroxysmal atrial fibrillation. Successful screening for atrial fibrillation in this high risk group allows the commencement of acceptable and safe anticoagulant therapy.

scholarly journals Cryptogenic Stroke

2017 ◽  
pp. 62
Author(s):  
Mohammad Saadatnia
Keyword(s):  
Atrial Fibrillation ◽  
Paroxysmal Atrial Fibrillation ◽  
Brain Infarction ◽  
Significant Proportion ◽  
Cryptogenic Stroke ◽  
Paradoxical Embolism ◽  
Embolic Stroke ◽  
Cardiac Monitoring ◽  
Large Artery ◽  
Extensive Evaluation

Cryptogenic stroke is defined as brain infarction that is not attributable to a source of definite embolism, large artery atherosclerosis, or small artery disease despite a thorough vascular, cardiac, and serologic evaluation. Despite many advances in our understanding of ischemic stroke, cryptogenic strokes remain a diagnostic and therapeutic challenge.The pathophysiology of cryptogenic stroke is likely various. Probable mechanisms include cardiac embolism secondary to occult paroxysmal atrial fibrillation, aortic atheromatous disease or other cardiac sources, paradoxical embolism from atrial septal abnormalities such as patent foramen ovale, hypercoagulable states, and preclinical or subclinical cerebrovascular disease.  Cryptogenic stroke is one-fourth among cerebral infarction, but most of them could be ascribed to embolic stroke. A significant proportion of cryptogenic strokes adhere to embolic infarct topography on brain imaging and improvement in our ability to detect paroxysmal atrial fibrillation in patients with cryptogenic stroke has strengthened the idea that these strokes are embolic in nature. a significant proportion of cryptogenic strokes adhere to embolic infarct topography on brain imaging.embolic stroke of undetermined sources(ESUS) was planned for unifying embolic stroke of undetermined source.  The etiologies underlying ESUS included minor-risk potential cardioembolic sources, covert paroxysmal atrial fibrillation, cancer-associated coagulopathy and embolism, arteriogenic emboli, and paroxysmal embolism. Extensive evaluation including transesophageal echocardiography and cardiac monitoring for long time could identify the etiology of these patients. Therefore cryptogenic stroke is a diagnosis of exclusion. Compared with other stroke subtypes, cryptogenic stroke tends to have a better prognosis and lower long-term risk of recurrence.   

scholarly journals Efficacy and safety of butylphthalide for patients who had acute ischaemic stroke receiving intravenous thrombolysis or endovascular treatment (BAST trial): study protocol for a randomised placebo-controlled trial

BMJ Open ◽  
2021 ◽  
Vol 11 (5) ◽  
pp. e045559
Author(s):  
Xuelei Zhang ◽  
Anxin Wang ◽  
Jing Yu Zhang ◽  
Baixue Jia ◽  
Xiaochuan Huo ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Endovascular Treatment ◽  
Functional Outcome ◽  
Acute Ischaemic Stroke ◽  
Controlled Trial ◽  
Intravenous Thrombolysis ◽  
Serious Adverse Events ◽  
Double Blind ◽  
Ischaemic Injury ◽  
Study Results

IntroductionAs a neuroprotective medication, butylphthalide (NBP) may help protect against cerebral ischaemic injury. However, evidence on whether NBP influences the outcomes of patients who had acute ischaemic stroke who are receiving revascularisation treatment is limited. This study aims to evaluate whether additional NBP therapy can improve the functional outcome of patients who receive intravenous recombinant tissue plasminogen activator and/or endovascular treatment (EVT).Methods and analysisThe study will be a randomised, double-blind, placebo-controlled, multiple-centre, parallel group trial. The sample size is estimated at 1200 patients. Eligible patients will be randomised at a 1:1 ratio to receive either NBP or placebo daily for 90 days, which will include 14 days of injections and 76 days of capsules. The first use of NBP/placebo will be started within 6 hours of onset of ischaemic stroke. The primary outcome is the functional outcome as assessed by the 90-day modified Rankin Scale, adjusted for baseline scores on the National Institutes of Health Stroke Scale. The primary safety outcome is the percentage of serious adverse events during the 90 days of treatment. This trial will determine whether NBP medication benefits patients who had acute ischaemic stroke who receive intravenous thrombolysis or EVT.Ethics and disseminationThe protocol was written according to the general ethical guidelines of the Declaration of Helsinki and approved by the Institutional Review Board/Ethics Committee of Beijing Tiantan Hospital, Capital Medical University with approval number KY 2018-003-02. Ethics committees of all participating sites have approved the study . Results of the study will be published in peer-reviewed scientific journals and shared in scientific presentations.Trial registration numberNCT03539445.

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.

scholarly journals Predictors of Development of Atrial Fibrillation in Patients With Embolic Stroke Of Undetermined Source: An Analysis of the RE-SPECT ESUS Trial

Circulation ◽  
2021 ◽  
Author(s):  
Maria Cecilia Bahit ◽  
Ralph L. Sacco ◽  
J. Donald Easton ◽  
Juliane Meyerhoff ◽  
Lisa Cronin ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Body Mass Index ◽  
Body Mass ◽  
Recurrent Stroke ◽  
Controlled Trial ◽  
Clinical Care ◽  
Important Variable ◽  
Older Age ◽  
Embolic Stroke ◽  
Cardiac Monitoring

Background: A proportion of patients with embolic stroke of undetermined source (ESUS) have silent atrial fibrillation (AF) or develop AF after the initial evaluation. Better understanding of risk for development of AF is critical to implement optimal monitoring strategies with the goal of preventing recurrent stroke due to underlying AF. The RE-SPECT ESUS trial provides an opportunity to assess predictors for developing AF and associated recurrent stroke. Methods: RE-SPECT ESUS was a randomized, controlled trial (564 sites, 42 countries) assessing dabigatran versus aspirin for the prevention of recurrent stroke in patients with ESUS. Of 5390 patients enrolled and followed for a median of 19 months, 403 (7.5%) were found to develop AF reported as an adverse event or using cardiac monitoring per standard clinical care. Univariable and multivariable regression analyses were performed to define predictors of AF. Results: In the multivariable model, older age (odds ratio [OR] for 10-year increase 1.99 [1.78-2.23]; P<0.001), hypertension (1.36 [1.03-1.79]; P=0.0304), diabetes (OR 0.74 [0.56-0.96]; P=0.022), and body mass index (OR for 5-unit increase 1.29 [1.16-1.43]; P<0.001) were independent predictors of AF during the study. In a sensitivity analysis restricted to 1117 patients with baseline N-terminal prohormone of brain natriuretic peptide (NT-proBNP) measurements, only older age and higher NT-proBNP were significant independent predictors of AF. Performances of several published predictive models were assessed, including the HAVOC and CHA2DS2-VASc scores, and higher scores were associated with higher rates of developing AF. Conclusions: Besides age as the most important variable, several other factors, including hypertension, higher body mass index, and lack of diabetes, are independent predictors of AF after ESUS. When baseline NT-proBNP was available, only older age and elevation of this biomarker were predictive of subsequent AF. Understanding who is at higher risk of developing AF will assist in identifying patients who may benefit from more intense, long-term cardiac monitoring.

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