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.

scholarly journals 122 Are We Effective Prescribers? A Retrospective Audit of DOAC Prescribing Post Embolic Stroke for Non Valvular Atrial Fibrillation

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Karen Dennehy ◽  
Joseph Morris ◽  
Diarmaid Hughes ◽  
Kate Donlon ◽  
Thomas Walsh
Keyword(s):  
Atrial Fibrillation ◽  
Renal Function ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Embolic Stroke ◽  
Haemorrhagic Transformation ◽  
Retrospective Audit ◽  
Online Laboratory ◽  
Number Of Patients

Abstract Background Direct oral anticoagulants (DOAC) are indicated for stroke prophylaxis in non-valvular atrial fibrillation, which is responsible for up to 20% of all ischaemic strokes(1). We performed a retrospective audit of all consecutive stroke patients in an Irish teaching hospital over a 1-year period to investigate the rate of incorrect dosing and any risk factors for this occurring. Methods We assessed our hospital stroke database from January to December 2017. Our research focused on DOAC prescribing in non valvular atrial fibrillation post embolic stroke. We collected data on baseline characteristics, choice of anticoagulation, dosing, and assessment of renal function, with follow up renal function if available. We reviewed electronic discharge summaries, online laboratory systems and completed a chart review. Results There was a total of 116 people with atrial fibrillation who developed an embolic stroke in our centre, of which 68 were eligible for anticoagulation using a DOAC (59). The main reasons for omission were CKD and haemorrhagic transformation. Patients were discharged on either Apixaban (32 patients), Rivaroxoban (32 patients), or Dabigatran (4 patients). Following our review, we established that 54/68 (79%) of patients were correctly anticoagulated. Over 20% of patients were incorrectly dosed and there was a clear tendency to under-dose 13/14 (93%). There were significant differences between the correct and incorrect dosing groups, with the latter group of patients being older and more at risk of polypharmacy. Renal function did not differ significantly between the groups at discharge or follow up and none of the incorrectly dosed patients were on a concurrent anti platelet. Conclusion A significant number of patients prescribed DOAC in hospital were not appropriately anticoagulated (21%), a majority of which were under-dosed. The patients who were under-dosed were older and more likely to be on 5 or more medications.

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.

scholarly journals Burden of oral anticoagulation in embolic stroke of undetermined source without atrial fibrillation

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Klaus K. Witte ◽  
Georgios Tsivgoulis ◽  
Matthew R. Reynolds ◽  
Stelios I. Tsintzos ◽  
Simon Eggington ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Recurrent Stroke ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Event ◽  
Cost Savings ◽  
Embolic Stroke ◽  
Bleeding Events ◽  
Event Rates

Abstract Objective Prevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies. Methods CRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective. Results Compared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient’s lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5953–£7018 per patient (UK), €6683–€7368 (Netherlands), €4933–€9378 (Spain), AUD$5353–6539 (Australia) and $26,768–$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $2468–$12,844 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years). Conclusions Anticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients.

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