Abstract WP231: Predictors for Early Atrial Fibrillation Detection Among Cryptogenic Stroke Patients with Insertable Cardiac Monitors: A Single-center Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ganesh Asaithambi ◽  
Jane E Monita ◽  
Sandra K Hanson
Keyword(s):  
Atrial Fibrillation ◽  
Cryptogenic Stroke ◽  
Single Center ◽  
Inclusion Criteria ◽  
Stroke Patients ◽  
Stroke Event ◽  
Single Center Experience ◽  
Pr Interval ◽  
Index Stroke ◽  
Left Atrial Dilatation

Background: The use of insertable cardiac monitors (ICM) has increased the rate of detection of atrial fibrillation (AF) among cryptogenic stroke (CS) patients. We describe a single-center experience for AF detection among CS patients receiving ICMs upon discharge after the index stroke event and attempt to identify predictors for early AF detection. Methods: From April 2014 to April 2016, patients receiving ICMs upon discharge for CS who underwent >90 days of monitoring were reviewed. Time from ICM placement to AF detection, chronic underlying medical illnesses, presence of left atrial dilatation (LAD) on echocardiography, and PR interval on admission EKG were assessed as predictors of early AF detection. Results: A total of 114 patients met inclusion criteria and were followed for a median of 415 [268, 557] days. Among these 32 patients (28.1%) were found to have AF at a median of 53 [5, 132] days from ICM placement. Patients with AF detected <30 days from ICM placement had lower rates of hyperlipidemia (35.7% vs 88.9%, p=0.003) and higher rates of hypertension (100% vs 66.7%, p=0.02), tobaccoism (85.7% vs 33.3%, p=0.005), LAD (64.3% vs 16.7%, p=0.01), and prolonged PR interval (195.3±43.2 ms vs 170.3±23.4 ms, p=0.04) compared to patients with AF detected >30 days from ICM placement. Conclusion: More than one-quarter of CS patients monitored for >90 days with an ICM were found to have previously undiagnosed AF. The majority of patients with AF detected were identified >30 days after their index CS event. Among patients in whom AF was ultimately detected by the ICM, AF may be identified earlier among patients with hypertension and tobaccoism in combination with LAD and prolonged PR interval. Prospective studies are needed to better identify predictors for early AF among the broader population of all CS patients.

Frequent Premature Atrial Contractions in Cryptogenic Stroke Predict Atrial Fibrillation Detection with Insertable Cardiac Monitoring

2020 ◽  
Vol 49 (2) ◽  
pp. 144-150 ◽  
Author(s):  
Kenichi Todo ◽  
Tomonori Iwata ◽  
Ryosuke Doijiri ◽  
Hiroshi Yamagami ◽  
Masafumi Morimoto ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
High Frequency ◽  
Strong Predictor ◽  
Cryptogenic Stroke ◽  
High Plasma ◽  
Cardiac Monitoring ◽  
Stroke Patients ◽  
Chads2 Score ◽  
Index Stroke

Objective: To determine whether frequent premature atrial contractions (PAC) predict atrial fibrillation (AF) in cryptogenic stroke patients, we analyzed the association between frequent PACs in 24-h Holter electrocardiogram recording and AF detected by insertable cardiac monitoring (ICM). Methods: We retrospectively analyzed a database of 66 consecutive patients with cryptogenic stroke who received ICM implantation between October 2016 and March 2018 at 5 stroke centers. We included the follow-up data until June 2018 in this analysis. We defined frequent PACs as the upper quartile of the 66 patients. We analyzed the association of frequent PACs with AF detected by ICM. Results: Frequent PACs were defined as >222 PACs per a 24-h period. The proportion of patients with newly detected AF by ICM was higher in patients with frequent PACs than those without (50% [8/16] vs. 22% [11/50], p < 0.05). Frequent PACs were associated with AF detection and time to the first AF after adjustment for CHADS2 score after index stroke, high plasma ­B-type natriuretic peptide (BNP; >100 pg/mL) or serum ­N-terminal pro-BNP levels (>300 pg/mL), and large left atrial diameter (≥45 mm). Conclusion: High frequency of PACs in cryptogenic stroke may be a strong predictor of AF detected by ICM.

Abstract P654: Predicting Afib in Cryptogenic Ischemic Stroke Patients With Implantable Loop Recorders

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Claribel D Wee ◽  
Tejeswi Suryadevara ◽  
Husitha Vanguru ◽  
Rashid Ahmed ◽  
Danielle Hawley ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Median Time ◽  
Scoring System ◽  
Cryptogenic Stroke ◽  
Stroke Patients ◽  
Stroke Event ◽  
Loop Recorder ◽  
Index Stroke ◽  
Chart Abstraction ◽  
History Of

Paroxysmal atrial fibrillation (Afib) detection in cryptogenic stroke is difficult but essential because it changes management. We describe a scoring system that discriminates between cryptogenic ischemic stroke patients with implantable loop recorder (ILR) that were and were not found to have Afib. Consecutive cryptogenic stroke cases from cardiology’s ILR registry for a 2-year period (7/2017-7/2019) were reviewed. We used standardized case report forms to perform chart abstraction. Cases were excluded if ILR was not placed after the index stroke event, stroke etiology workup was not available, or data was incomplete. Patients found to have Afib on ILR were compared to those without evidence of Afib on ILR. We devised a novel scoring system using variables associated with Afib detection and compared its ability to classify Afib detection against CHA2DS2-VASc and LADS. One hundred fifty-seven patients met inclusion criteria. Afib was detected in 12% of cases (9% at 6 months, 10% at 12 months). The median time from ILR placement to Afib detection was 110 days (IQR 37, 507). Median time from Afib detection to the start of anticoagulation was 3 days (IQR 0, 8). The PAL-CrISP score ranges 0 to 7: age (70=0, ≥70=4), history of antihypertensive medication (no=0, yes=2), PR interval (≤200msec=0, >200msec=1). Of those found to have Afib via ILR, 74% (14/19) had a PAL-CrISP score ≥ 6. PAL-CrISP performed better at predicting Afib detection in cryptogenic ischemic stroke patients with ILR (AUC 0.810, 95% CI 0.706-0.913) than CHA2DS2-VASc (AUC 0.650, 95% CI 0.525-0.774) and LADS (AUC 0.745, 95% CI 0.624-0.866). Using only age, home medication review, and an EKG, the novel PAL-CrISP score performs better at predicting Afib detection than the CHA2DS2-VASc and LADS scores in cryptogenic ischemic stroke patients with an ILR.

Incidence of atrial fibrillation among patients with an embolic stroke of undetermined source: Insights from insertable cardiac monitors

2018 ◽  
Vol 14 (2) ◽  
pp. 146-153 ◽  
Author(s):  
Nishant Verma ◽  
Paul D Ziegler ◽  
Shufeng Liu ◽  
Rod S Passman
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Cryptogenic Stroke ◽  
Embolic Stroke ◽  
Inclusion Criteria ◽  
Stroke Patients ◽  
Detection Rates ◽  
Prophylactic Use ◽  
Atrial Fibrillation Trial

Background Prophylactic use of direct oral anticoagulants for recurrent stroke prevention in patients with embolic strokes of undetermined source is currently being investigated. It is uncertain whether the bleeding risks associated with prophylactic direct oral anticoagulants use will outweigh any stroke prevention benefit in embolic strokes of undetermined source patients who lack underlying atrial fibrillation. Methods We determined the proportion of cryptogenic stroke patients in the CRYSTAL atrial fibrillation trial who met inclusion criteria for the NAVIGATE embolic stroke of undetermined source and RE-SPECT embolic stroke of undetermined source trials and their atrial fibrillation incidence. Both embolic strokes of undetermined source trials impose requirements on age, modified Rankin Score, antiplatelet use, and type of infarction. Insertable cardiac monitors were used to determine the atrial fibrillation detection rates at 30 days and 3 years using Kaplan–Meier’s estimates. Results Among 441 patients enrolled in the CRYSTAL atrial fibrillation trial, 189 (42.9%) and 236 (53.5%) met the inclusion criteria of the NAVIGATE embolic stroke of undetermined source and RE-SPECT embolic stroke of undetermined source trials, respectively. Atrial fibrillation detection rates at 3 years among insertable cardiac monitors patients eligible for the NAVIGATE embolic stroke of undetermined source and RE-SPECT embolic stroke of undetermined source trials were 35.8% and 33.6% while detection rates at 30 days were 5.6% and 3.5%, respectively. Conclusion Only half of cryptogenic stroke patients in CRYSTAL atrial fibrillation met the inclusion criteria for the ongoing embolic strokes of undetermined source trials. Approximately, two-thirds of patients with embolic strokes of undetermined source do not have any atrial fibrillation despite continuous rhythm monitoring for up to three years. The benefits of prophylactic use of direct oral anticoagulants in the absence of atrial fibrillation is unknown and therefore embolic strokes of undetermined source patients could benefit from prolonged atrial fibrillation monitoring until more robust data are available. ClinicalTrials.gov Registration NCT00924638. https://clinicaltrials.gov/ct2/show/NCT00924638 .

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.

Prevalence of atrial fibrillation with insertable cardiac monitors in cryptogenic stroke: A single-center experience

2018 ◽  
Vol 51 (6) ◽  
pp. 973-976 ◽  
Author(s):  
Ganesh Asaithambi ◽  
Jane E. Monita ◽  
M. Ramu Annamalai ◽  
Bridget M. Ho ◽  
Emily H. Marino ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cryptogenic Stroke ◽  
Single Center ◽  
Single Center Experience

Rhythm outcome predictors after concomitant surgical ablation for atrial fibrillation: Ten-year single-center experience

2014 ◽  
Vol 62 (S 01) ◽  
Author(s):  
S. Pecha ◽  
T. Schäfer ◽  
T. Ahmadzade ◽  
I. Subbotina ◽  
S. Willems ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Outcome Predictors ◽  
Single Center ◽  
Surgical Ablation ◽  
Single Center Experience

scholarly journals B-PO01-028 UTILIZATION OF CARDIAC MONITORING FOR ATRIAL FIBRILLATION IN CRYPTOGENIC STROKE PATIENTS

Heart Rhythm ◽  
2021 ◽  
Vol 18 (8) ◽  
pp. S62
Author(s):  
Matthew R. Reynolds ◽  
Candace L. Gunnarsson ◽  
Michael P. Ryan ◽  
Sarah Rosemas ◽  
Paul D. Ziegler ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Cryptogenic Stroke ◽  
Cardiac Monitoring ◽  
Stroke Patients

Abstract P630: Detection of Atrial Fibrillation by Prolonged Cardiac Monitoring in Cryptogenic and Known Stroke Etiology

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Michal krawczyk ◽  
Sebastián Fridman ◽  
Maria Bres Bullrich ◽  
Palak Shah ◽  
Juan C Vargas-Gonzalez ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Logistic Regression ◽  
Cryptogenic Stroke ◽  
Left Atrial Volume ◽  
Cardiac Monitoring ◽  
Volume Index ◽  
Multivariate Logistic Regression Model ◽  
Stroke Patients ◽  
Cross Sectional ◽  
Therapeutic Decisions

Introduction: Approximately 25% of strokes are classified as cryptogenic (CS), while greater than 50% have an identifiable or ‘known’ etiology (KS). Several studies have demonstrated that prolonged cardiac monitoring (PCM) after cryptogenic stroke substantially increases the detection of atrial fibrillation (AF), but the yield of PCM in KS stroke is unknown. As a result, the majority of guidelines recommend restricting PCM to patients with cryptogenic stroke. If the detection of AF in KS is no different to cryptogenic stroke, it would suggest that this group too would similarly benefit from PCM, with the potential to impact therapeutic decisions (e.g. initiating anticoagulation). Methods: In a cross-sectional study, we compared AF detection by PCM (minimum of 48 hrs) between CS and KS patients without a previous diagnosis of AF. We developed a multivariate logistic regression model by including known and significant clinical, echocardiographic, and radiological factors known to be associated with the detection of AF. We reported results as odds ratios (OR) and 95% confidence intervals (95% CI). Results: We included 561 ischemic stroke patients, 376 with CS and 185 with KS. The median duration of PCM was 167h for CS and 48h for KS. AF was detected in 30 of 376 (8%) CS patients, and 20 of 185 (7.9%) KS patients. Age, history of thyroid disease, clinical presentation of dysarthria, wake-up stroke, and left atrial volume index on echocardiography were significantly associated with a new diagnosis of AF after stroke in the univariable analysis and were thus included in the logistic regression analysis. Additionally, duration of PCM was included in the multivariate model. After adjustment for potential confounders, AF detection by PCM was not significantly higher for CS than KS (OR 0.95, 95% CI 0.25-3.32, P=0.94). Conclusion: To the best of our knowledge this is the first study directly comparing the incidence of AF between CS and KS as the pre-specified primary outcome. Our findings suggest that CS and KS patients have similar rates of AF detection by PCM. Future prospective research is required to confirm these findings and to determine the cost-effectiveness of PCM in non-cryptogenic stroke patients.

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