Mobile Cardiac Outpatient Telemetry Patch vs Implantable Loop Recorder in Cryptogenic Stroke Patients in the US – Cost-Minimization Model

Introduction: The RESPECT-ESUS trial is proposed to evaluate the best stroke prevention strategy for patients with strokes of uncertain etiology. This trial will compare a novel anticoagulant with antiplatelet agents to prevent recurrent stroke among cryptogenic stroke patients. We sought to evaluate the eligibility for this trial within a large, biracial population representative of the US. Methods: All adult ischemic stroke patients in 2010 among residents of the 5-county Greater Cincinnati/Northern Kentucky region (population 1.3 million) were ascertained from all local hospitals via ICD-9 codes 430-436. Inclusion and exclusion criteria supplied by the corporate sponsor as of 6/30/14 were applied to the ischemic stroke population. Per trial protocol, a complete workup was defined as brain and both intra- and extracranial vascular imaging, ECHO, telemetry, and EKG. Results: Of 1894 ischemic stroke patients without hemorrhagic transformation who survived the hospital stay (and not sent to hospice), 138 (7.4%) would have been eligible for RESPECT-ESUS. Inclusion and exclusion criteria are listed in the Table. If we were to assume that every stroke patient received a complete workup and no further etiologies were identified, the “hypothetical” eligibility could be as high as 18.7%. Discussion: We found that the potential eligibility for the RESPECT-ESUS trial to be low, and in fact is similar to population-based estimates of rt-PA eligibility (6%-8%). Extrapolation of eligibility across the US would be further limited by presentation to an enrolling center and consent refusal rates. Our estimates are based on information obtained during hospitalization, which may over- or underestimate eligibility within the 3-6 month post-event enrollment window. It is likely that centers that participate in the trial will have more complete diagnostic workups, which was a major exclusion in our population, especially the requirement for intracranial vascular imaging.

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Presence of Atrial Fibrillation in Stroke Patients With Patent Foramen Ovale: Systematic Review and Meta-Analysis

Frontiers in Neurology ◽

10.3389/fneur.2021.613758 ◽

2021 ◽

Vol 12 ◽

Author(s):

Jessie Ze-Jun Chen ◽

Vincent N. Thijs

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Confidence Interval ◽

Lower Risk ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Stroke Patients ◽

Loop Recorder ◽

Cross Sectional

Purpose: Patent foramen ovale (PFO) is associated with ischemic stroke, especially in patients with embolic stroke of undetermined source. This study aims to evaluate the presence of atrial fibrillation (AF) in ischemic stroke patients with PFO.Methods: We systematically searched EMBASE and MEDLINE databases on May 21, 2020 for studies that analyzed the presence of AF in patients with PFO. The primary outcome was the presence of AF in patients with PFO compared with those without. Outcomes were pooled using a random-effects model using the method of DerSimonian and Laird. We recorded demographic characteristics and the methods used for AF detection in the studies included (unspecified, history/medical records review, ECG, Holter monitor, or loop recorder).Results: A total of 14 studies and 13,245 patients fulfilled the entry criteria. The average age was 61.2 years and 41.3% of the participants were female. There was a lower risk of AF in patients with PFO compared with those without (RR 0.52, 95% confidence interval, 0.41–0.63, p < 0.001). There was no evidence of heterogeneity. The lower risk of AF was found in cross-sectional and longitudinal studies and in studies stratified by average age (<60 or ≥60) and in cryptogenic stroke. Meta-regression by PFO detection technique suggested that studies using transoesophageal echocardiogram for PFO detection reported higher risk of AF (1.39, 95% confidence interval 1.14–1.70, p = 0.004).Conclusion: The presence of a PFO in patients with ischemic stroke/TIA may be associated with a lower risk of AF. Few studies have estimated the risk of future AF in patients with PFO.

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

Stroke ◽

10.1161/str.52.suppl_1.p654 ◽

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.

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