Stroke Patients With Suspected Atrial Fibrillation Should NOT Be Started on Anticoagulation WHILE AWAITING the Results of 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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First clinical experience with the wearable cardiac rhythm long-term monitoring cardioskin device

European Heart Journal ◽

10.1093/ehjci/ehaa946.3464 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

P Guedeney ◽

J Silvain ◽

F Hidden-Lucet ◽

C Maupain ◽

S Dinanian ◽

...

Keyword(s):

Atrial Fibrillation ◽

Clinical Practice ◽

Cardiac Rhythm ◽

Cardiac Monitoring ◽

Funding Source ◽

Single Center ◽

Long Term Monitoring ◽

Monitoring Devices ◽

Term Monitoring

Abstract Background There are only limited options for long-term cardiac monitoring devices readily available in clinical practice for outpatients. Holter monitoring devices are limited by the uncomfort of wires and patches, the small number of leads for analysis, the quality of recordings or the monitoring duration while insertable cardiac monitors are costly and exposed to potential local complication. Purpose To describe a single center experience with a novel wearable device for cardiac rhythm monitoring. Methods The Cardioskin™ system is a patch-free, wire-free, wearable device with rechargeable batteries that provides a high quality 15-lead electrocardiogram monitoring over 1 month (Figure 1). Data are sent using a mobile application downloaded in the patient smartphone to a central Corelab where they can be interpreted by an expert and/or the prescribing physician. An alarm signal is readily available within the Cardioskin™ device, to allow patients to indicate the presence of symptoms. In this single center retrospective registry, we provide a first report of the use of this novel device in real world practice, with indication and duration of cardiac monitoring left at the physicans “discretion”. Results From January 2019 to December 2019, the Cardioskin™ system was prescribed in 60 patients for an overall median duration of 26.5 (14–32) days. The mean age of the patients was 45±12.2 years and 24 (40%) were male. Indications for cardiac monitoring were post-Stroke, palpitation, syncope and cardiomyopathy assessment in 56%, 30%, 7% and 7% of the cases, respectively. A sustained (>30 seconds) supraventricular tachycardia was detected in 4 cases, including one case of atrial fibrillation, two case of atrial tachycardia and on case of junctional tachycardia. Unsustained ventricular tachycardia and atrial fibrillation burst were detected in another 2 cases (Figure 1). There was no reported case of skin irritation by the Cardioskin™ system or abrupt interruption of the monitoring by the patients. Conclusion The Cardioskin™ system is a novel, discreet and comfortable cardiac rhythm wearable long-term monitoring device which can be used in clinical practice for broad diagnostic indications. Figure 1. Cardioskin system Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): ACTION coeur

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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 176: Long Term Mortality in Acute Ischemic Stroke Patients with Nonvalvular Atrial Fibrillation According to Location and Burden of Cerebral Microbleeds

Stroke ◽

10.1161/str.45.suppl_1.176 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Tae-Jin Song ◽

Jinkwon Kim ◽

Dongbeom Song ◽

Yong-Jae Kim ◽

Hyo Suk Nam ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Hemorrhagic Stroke ◽

Independent Predictor ◽

Stroke Patients ◽

Risk Of Death ◽

Long Term Mortality

Background: Cerebral microbleeds (CMBs) were predictive of mortality in elderly and considered as a putative marker for risk of intracranial hemorrhage. Stroke patients with non valvular atrial fibrillation (NVAF) require anticoagulation, which increases the risk of hemorrhages. We investigated association of CMBs with the long term mortality in acute ischemic stroke patients with NVAF. Methods: During 6 years , consecutive ischemic stroke patients who had NVAF and who had undergone brain MRI with a gradient-recalled echo sequence were enrolled. Long-term mortality and causes of death were identified using data from Korean National Statistical Office. Survival analysis was performed whether the presence, number and location of CMBs were related with all causes, cardiovascular, and cerebrovascular mortality during follow-up. Results: Total 506 patients were enrolled during the study period and were followed up for median 2.5 years. CMBs were found in 30.8% of patients (156/506). Oral anticoagulation with warfarin was prescribed at discharge in 477 (82.7%) patients. During follow up, 177 (35%) patients died and cerebrovascular death was noted in 93 patients (81 ischemic stroke and 12 hemorrhagic stroke). After adjusting age, sex and significant variables in univariate analysis (p<0.1), multiple CMBs (≥5) were the independent predictor for all-cause, cardiovascular and ischemic stroke mortalities. The strictly lobar CMBs were associated with hemorrhagic stroke mortality in multivariate Cox regression analysis (HR 4.776, p=0.032) (Figure 1). Conclusions: Multiple CMBs were the independent predictor for the long term mortality in stroke patients with NVAF. Among them, patients with strictly lobar CMBs had a high risk of death due to hemorrhagic stroke. Our findings suggest that detection of CMBs in stroke patients with NVAF are of clinical relevance for predicting long term outcome and that particular concern is necessary in those with strictly lobar CMBs for their increased risk of death due to hemorrhagic stroke. Figure 1.

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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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Abstract WP379: Sex-specific Effects of Comorbid Diabetes and Depression on Post-stroke Mortality in Individuals With Atrial Fibrillation

Stroke ◽

10.1161/str.51.suppl_1.wp379 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Jodi Edwards ◽

Jessica Colby-Milley ◽

Jiming Fang ◽

Limei Zhou ◽

Baiju R Shah ◽

...

Keyword(s):

Atrial Fibrillation ◽

Hospital Mortality ◽

Recurrent Stroke ◽

Stroke Patients ◽

Comorbid Depression ◽

Term Care ◽

Post Stroke ◽

Specific Effects ◽

Long Term Mortality

Background: Comorbid diabetes and depression are highly prevalent in atrial fibrillation (AF) and increase the risk of stroke. Women with AF show higher mortality rates and have worse functional outcomes post-stroke. However, the sex-specific effects of comorbid diabetes and depression on mortality and other adverse outcomes in stroke patients with a history of AF is unclear. Methods: Prospectively collected consecutive patients with ischemic stroke and known AF presenting to designated stroke centres in Ontario (2003-2013). Multinomial regression was used to determine sex-specific associations between diabetes and depression and in-hospital mortality post-stroke in individuals with AF. Cox proportional hazards regression was used to estimate the adjusted hazard of long-term mortality post-stroke and competing risks models to estimate hazards of recurrent stroke/TIA, admission to long-term care, and incident dementia post-discharge. Results: Among 5082 stroke patients with known AF (median age=80, IQR:73-85), female patients were more likely to have comorbid depression than males (63.5% vs. 36.5%) and those with comorbid diabetes and depression were younger (77 yrs) and had more vascular history (HTN, CAD, hyperlipidemia) than those with AF only. For males, comorbid diabetes increased the likelihood of in-hospital mortality post-stroke by 53% (OR=1.53, 95% CI=1.16-2.02), after adjustment for stroke severity, demographic and clinical factors, while comorbid depression did not significantly impact in-hospital mortality and neither diabetes or depression affected in-hospital mortality post-stroke for females. However, diabetes was independently associated with increased hazard of long-term mortality for both female (HR=1.15, 95%CI=1.02-1.29) and male AF stroke patients (HR=1.35, 95%CI=1.19-1.53). No associations with recurrent stroke/TIA, institutionalization or dementia post-stroke were observed for either females or males. Conclusion: In stroke patients with known AF, comorbid diabetes but not depression was independently associated with increased in-hospital mortality for males and increased long-term mortality post-stroke for both females and males.

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