Abstract WP257: Occurrence and Imaging Patterns of Recurrent Strokes iIn a Cohort of Cryptogenic Stroke Patients on Long Term Cardiac Monitoring

Stroke kills or disables millions of people every year. If the cause of a stroke is known, it is often possible to reduce the risk of a second stroke by appropriate patient management. However, up to a third of all ischaemic strokes remain cryptogenic, with no identified cause. Many of these strokes are suspected to be due to atrial fibrillation (AF), which is difficult to diagnose accurately. Small, leadless, insertable cardiac monitors (ICMs) gather data over three years, making them superior to other monitoring methods. The current review surveys the substantial supporting clinical data for the ICM Reveal XT, including the recently completed CRYSTAL-AF randomised clinical trial. The results consistently report previously undiagnosed AF in around 30 % of patients with cryptogenic stroke. ICM-provided data have direct consequences, as patients with AF-related stroke are indicated for protective oral anticoagulant therapies. Thus, ICMs will be important in the management of cryptogenic stroke, identifying and enabling patients with AF to receive life-saving therapies.

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

Heart Rhythm ◽

10.1016/j.hrthm.2021.06.174 ◽

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

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

Stroke ◽

10.1161/str.52.suppl_1.p630 ◽

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

Stroke Research and Treatment ◽

10.4061/2011/172074 ◽

2011 ◽

Vol 2011 ◽

pp. 1-5 ◽

Cited By ~ 14

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

Cerebrovascular Diseases ◽

10.1159/000505958 ◽

2020 ◽

Vol 49 (2) ◽

pp. 144-150 ◽

Cited By ~ 2

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.

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D-dimer for prediction of long-term outcome in cryptogenic stroke patients with patent foramen ovale

Thrombosis and Haemostasis ◽

10.1160/th14-12-1040 ◽

2015 ◽

Vol 114 (09) ◽

pp. 614-622 ◽

Cited By ~ 5

Author(s):

Young Dae Kim ◽

Dongbeom Song ◽

Hyo Suk Nam ◽

Kijeong Lee ◽

Joonsang Yoo ◽

...

Keyword(s):

Ischaemic Stroke ◽

Patent Foramen Ovale ◽

Pulmonary Thromboembolism ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Stroke Patients ◽

Term Outcome ◽

Long Term Outcome ◽

D Dimer

SummaryPatent foramen ovale (PFO) is a potential cause of cryptogenic stroke, given the possibility of paradoxical embolism from venous to systemic circulation. D-dimer level is used to screen venous thrombosis. We investigated the risk of embolism and mortality according to the presence of PFO and D-dimer levels in cryptogenic stroke patients. A total of 570 first-ever cryptogenic stroke patients who underwent transesophageal echocardiography were included in this study. D-dimer was assessed using latex agglutination assay during admission. The association of long-term outcomes with the presence of PFO and D-dimer levels was investigated. PFO was detected in 241 patients (42.3 %). During a mean 34.0 ± 22.8 months of follow-up, all-cause death occurred in 58 (10.2 %) patients, ischaemic stroke in 33 (5.8 %), and pulmonary thromboembolism in 6 (1.1 %). Multivariate Cox regression analysis showed that a D-dimer level of > 1,000 ng/ml was an independent predictor for recurrent ischaemic stroke in patients with PFO (hazard ratio 5.341, 95 % confidence interval 1.648–17.309, p=0.005), but not in those without PFO. However, in patients without PFO, a D-dimer level of > 1,000 ng/ml was independently related with all-cause mortality. The risk of pulmonary thromboembolism tended to be high in patients with high D-dimer levels, regardless of PFO. Elevated D-dimer levels in cryptogenic stroke were predictive of the long-term outcome, which differed according to the presence of PFO. The coexistence of PFO and a high D-dimer level increased the risk of recurrent ischaemic stroke. The D-dimer test in cryptogenic stroke patients may be useful for predicting outcomes and deciding treatment strategy.

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