ECG monitoring with implanted monitors increased AF detection more than usual follow-up after cryptogenic stroke

Aim. To estimate the efficacy of invasive and non-invasive long-term ECG monitoring in comparison with conventional follow-up for the detection of silent atrial fibrillation (AF)/atrial flutter (AFL)/atrial tachycardia (AT) in patients with a cryptogenic stroke.Methods. The randomized, prospective, two-center study enrolled 36 patients who suffered cryptogenic stroke (CS) or transient ischemic attack (TIA) without past history of AF/AFL/AT. Patients were randomized in a 1:1:1 ratio to one of the three ECG monitoring strategies: standard arrhythmia monitoring (group I, n=12), ECG-monitoring with implantable loop recorder (group II, n=12), and ambulatory noninvasive ECG monitoring (group III, n=12). The primary endpoint was the time to the first detection of AF/AFL/AT. Patients, assigned to the group I, underwent an assessment at scheduled and unscheduled visits and received ambulatory ECG monitoring 28 days and 1 year after randomization. Patients in the group II underwent implantation of Reveal XT (Medtronic, USA) with the daily remote data transmission to CareLink Network. In the group III, for long-term external monitoring, Spyder system (WEB Biotechnology, Singapore) was used for up to 28 days.Results. During the first 28 days of observation, there were no significant differences in AF detection rates between groups I, II, and III: 0 (0%), 1 (8%), and 2 (17%) cases, respectively, р=0.537. During the year of observation, AF/AFL/AT episodes were detected in 1 case (8%) in the group I, 6 cases (50%) in the group II, and 2 cases (17%) in the group III, p=0.0486. The mean time from enrollment into the study to detection of the first AF/AFL/AT episode was 67 days (15; 97) in all groups. In the groups II and III, the first arrhythmia episodes were detected by monitoring devices on days 24 and 6, respectively. In most cases, arrhythmia episodes detected by long-term monitoring were asymptomatic. Recurrent stroke or TIA events occurred in group I and III (1 case in each group), but not in the group with implantable cardiac monitors. Subgroup analysis showed that significantly higher AF/AFL/AT detection rate was associated with stroke, CHA2DS2VASc score ≥2, and the presence of hypertension. For the 12 months of follow-up, the mean AF burden in the group II was 0.4 (0.2; 0.5) hours per day (1.6%). In the patients with recurrent stroke, AF burden was 3.2% compared to 0.9% in the rest of patients.Conclusion. Detection of silent AF with implantable cardiac monitors is superior to standard and long-term external monitoring in cryptogenic stroke patients.

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Incidence and type of arrhythmias recorded by one-month continuous ECG monitoring in stroke patients

EP Europace ◽

10.1093/europace/euab116.030 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

S Castrejon Castrejon ◽

G Ruiz-Ares ◽

M Martinez Cossiani ◽

R Rigual ◽

R Gutierrez Zuniga ◽

...

Keyword(s):

Cryptogenic Stroke ◽

Paroxysmal Supraventricular Tachycardia ◽

Av Block ◽

Ecg Monitoring ◽

Recording Time ◽

Non Invasive ◽

Funding Sources ◽

Ectopic Beats ◽

Sinus Dysfunction

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND The incidence of atrial fibrillation (AF) following stroke has been studied with implantable loop recorders. However, these devices do not record short lasting AF episodes (<30-120 seconds [s]). In addition, the incidence and type of other clinically relevant arrhythmias is poorly understood in this clinical setting. PURPOSE To evaluate the incidence, type and clinical relevance of arrhythmias detected by one-month continuous ECG monitoring in patients after cryptogenic stroke. MATERIAL AND METHODS Consecutive patients (p) with stroke and no previous AF or other cardioembolic or atheroembolic causes were prospectively enrolled in the study. An external wearable 2-lead ECG monitoring system (NUUBO) was used for 30 days (d) in all of them after the acute phase of the stroke. In the absence of documented AF, a parafibrillatory status was defined as >3000 atrial ectopic beats/d or >2 "micro AF" episodes (fibrillatory burst <30 s)/d or ≥1 episode of "micro AF" >14 s. RESULTS 130 p. were included in the study (age 73 ± 12, 57% males, 19% previous stroke, 7% ischemic cardiopathy, CHA2DSVA2Sc pre-stroke 3.1 ± 1.7). 3 were withdrawn from the study due to inadequate use (recording time <14 d) and 1 due to stroke during SARS-CoV2 infection. Total recording time was 28 ± 3 d, total analyzable ECG time was 23 ± 5 d. ECG monitoring was repeated in 12 (9.5%) p due to poor ECG quality in 6 p or high suspicion of AF despite an initial negative result in 6 p. AF >30 s was detected in a total of 27 (21.4%) p, average AF duration was 52 hours (range 30 s-22 d). AF >30s was detected in 2 (17%) p with repeated monitoring. All these patients were placed on anticoagulation. Sustained paroxysmal supraventricular tachycardia (SVT) was documented in 4 (4.4%) p without AF. All episodes of AF and SVT were asymptomatic. Mobitz I second degree AV block in 4 (3.2%) p. 3 (2.4%) p had a pacemaker implanted: 2 for severe sinus dysfunction and 1 for AV block. High-density ventricular ectopy (>3000/d) was present in 7 (6%) p and ≥1 episode of non-sustained ventricular tachycardia was detected in 26 (21%) p. A parafibrillatory status was identified in 27 (21%) p with no AF >30 s. At 1-year follow up 4/22 (18%) of patients with parafibrillatory status and 3/59 (5%) without parafibrillatory status suffered a new stroke (p = 0.08). CONCLUSIONS AF and other potentially relevant arrhythmias are frequent after stroke and easily detectable with one-month non-invasive continuous ECG monitoring. Patients with a parafibrillatory status could benefit from longer monitoring time to detect AF.

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Supraventricular Runs in 7-Day Holter Monitoring Are Related to Increased Incidence of Atrial Fibrillation in a 3-Year Follow-Up of Cryptogenic Stroke Patients Free from Arrhythmia in a 24 h-Holter

Journal of Cardiovascular Development and Disease ◽

10.3390/jcdd8070081 ◽

2021 ◽

Vol 8 (7) ◽

pp. 81

Author(s):

Andrzej Kułach ◽

Milena Dewerenda ◽

Michał Majewski ◽

Anetta Lasek-Bal ◽

Zbigniew Gąsior

Keyword(s):

Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Holter Monitoring ◽

Ecg Monitoring ◽

Stroke Patients ◽

Long Term Monitoring ◽

In Cis ◽

Term Monitoring

Introduction: Silent atrial fibrillation (AF) is a common cause of cryptogenic ischemic stroke (CIS). The 24-h-Holter is insufficient to reveal an occult arrhythmic cause of stroke and the strategy to select the patients for long-term monitoring is missing. Objectives: The aim of the study was to evaluate 7-day-Holter monitoring to identify cases with the arrhythmic cause of stroke in CIS patients in whom 24-h-Holter was free from arrhythmia, and to assess the relation between supraventricular (SV) runs in baseline Holter and the incidence of AF in a 3-year follow-up period. Methods: 78 patients (aged 60 ± 9 years, 45 males) with CIS and no arrhythmic findings in 24-h-Holter were enrolled. All patients had 7-day-Holter monitoring after stroke and were followed up for 36 months, and then 7-day Holter was repeated. We assessed SV runs (≥5 QRS) in the initial 7-day Holter and analyzed the relation of the findings with clinical characteristics of novel AF episodes revealed early after stroke and during a 3-year follow-up. Results: Baseline 7-day-Holter revealed SV runs in 36% of patients and AF in 9% of cases. During a 3-year follow-up, 8 additional cases were confirmed, both in standard care and in repeated Holter (a total of 19% of AF cases). There was no difference with regard to CHADS2VASc score (3.6 ± 1.1 vs. 3.4 ± 1.5; p = NS) and left atrium parameters between patients with SV runs and the non-arrhythmic group. Patients with SV runs had a higher incidence of AF both after stroke and in a 3-year follow-up (46% vs. 4%, RR 11.6, p < 0.001). In 8 cases, patent foramen ovale was detected during follow-up. Conclusions: A strategy of baseline 7-day-Holter monitoring after stroke allows for disclosing SV runs in every third case and AF in 9% of stroke survivors. Patients with SV runs have a higher incidence of AF (RR 11.6, p < 0.001) and should be considered for extended continuous ECG monitoring.

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Implantable cardiac monitor after cryptogenic stroke: atrial fibrillation detection and predictors

European Heart Journal ◽

10.1093/ehjci/ehaa946.0382 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

E Ebrille ◽

C Amellone ◽

M.T Lucciola ◽

F Orlando ◽

M Suppo ◽

...

Keyword(s):

Atrial Fibrillation ◽

Multivariate Analysis ◽

Risk Stratification ◽

Median Time ◽

Remote Monitoring ◽

Cryptogenic Stroke ◽

Screening Process ◽

Cardiac Monitor ◽

Implantable Cardiac Monitor

Abstract Objective The main objective of our study was to analyze the incidence and predictors of atrial fibrillation (AF) in patients with cryptogenic stroke (CS) who received an implantable cardiac monitor (ICM) at our Institution. Methods From November 2013 to October 2017, a total of 133 patients who had suffered a CS were implanted with an ICM after a thorough screening process. The median time between the thromboembolic event and ICM implantation was 64 days [IQ range: 16–111]. All implanted patients were followed with remote monitoring until the first detected episode of AF or up to December 2018. Every remote monitoring transmission and related electrograms were analyzed by the dedicated Electrophysiology Nursing team and confirmed by experienced Electrophysiologists. AF was defined by any episode lasting greater than or equal to 2 minutes. Results During a median follow-up of 14.8 months [IQ range: 3.0–31.2], AF was detected in 65 out of 133 patients (48.9%). The median time from ICM implantation and AF detection was 3.5 months [IQ range: 0.9–6.7]. The prevalence of AF was 22.6%, 34.4%, 40.8% and 48.3% at 3, 6, 12 and 24 months respectively. At the multivariate analysis, high premature atrial contractions (PAC) burden and left atrium (LA) dilation were the only independent predictors of AF detection (HR 2.82, 95% CI 1.64–4.83, p<0.001 for PAC; HR 1.75, 95% CI 1.03–2.97, p=0.038 for LA dimension). Patients were dived into categories based on the probability of AF detection (low, intermediate and high risk) and a new risk stratification algorithm was implemented (Figure 1). Conclusion After a thorough screening process, AF detection in patients with CS and ILM was quite high. Having a high PAC burden and LA dilation predicted AF episodes at the multivariate analysis. A new risk stratification algorithm was developed. Figure 1 Funding Acknowledgement Type of funding source: None

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Potential Biological Markers of Atrial Fibrillation: A Chance to Prevent Cryptogenic Stroke

BioMed Research International ◽

10.1155/2017/8153024 ◽

2017 ◽

Vol 2017 ◽

pp. 1-10 ◽

Cited By ~ 6

Author(s):

István Szegedi ◽

László Szapáry ◽

Péter Csécsei ◽

Zoltán Csanádi ◽

László Csiba

Keyword(s):

Atrial Fibrillation ◽

Biological Markers ◽

Cryptogenic Stroke ◽

Biological Marker ◽

Ecg Monitoring ◽

Inflammation Markers ◽

Good Patient ◽

Markers Of Inflammation ◽

Good Patient Compliance ◽

And Function

Stroke affects millions of people all over the world, causing death and disability. The most frequent type of this disease is ischemic stroke, which can be caused by different factors. In approximately 25 percent of cases, no obvious cause can be found. Recent observations have shown that paroxysmal atrial fibrillation could be responsible for a significant number of cryptogenic stroke events. Short- or long-lasting ECG monitoring could help with the diagnosis of transient arrhythmias. Unfortunately, these techniques either are expensive or require good patient compliance. An alternative option is the identification of biological markers that are specific for atrial fibrillation and can be used to predict arrhythmia. In this review, we give a summary of the recent advances in the research of arrhythmia markers. Based on their structure and function, we differentiated four groups of biomarkers: markers of inflammation, markers of fibrosis, markers with hormonal activity, and other markers. In spite of intensive researches, the optimal biological marker is still not available, but there are some promising markers, like NT-proBNP/BNP.

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Relevance of supraventricular runs detected after cerebral ischemia

Neurology ◽

10.1212/wnl.0000000000004487 ◽

2017 ◽

Vol 89 (15) ◽

pp. 1545-1552 ◽

Cited By ~ 8

Author(s):

Mark Weber-Krüger ◽

Constanze Lutz ◽

Antonia Zapf ◽

Raoul Stahrenberg ◽

Joachim Seegers ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cerebral Ischemia ◽

Ecg Monitoring ◽

Holter Ecg ◽

Acute Cerebral Ischemia ◽

Temporal Phenomenon ◽

Long Term Follow Up ◽

Recurrent Strokes

Objective:Prolonged ECG monitoring after stroke frequently reveals short paroxysmal atrial fibrillation (pAF) and supraventricular (SV) runs. The minimal duration of atrial fibrillation (AF) required to induce cardioembolism, the relevance of SV runs, and whether short pAF results from cerebral damage itself are currently being debated. We aimed to study the relevance of SV runs and short pAF detected by prolonged Holter ECG after cerebral ischemia during long-term follow-up.Methods:Analysis is from the prospective Find-AF trial (ISRCTN46104198). We included patients with acute cerebral ischemia. Those without AF on admission received 7-day Holter ECG monitoring. We differentiated patients with AF on admission (AF-adm), with pAF (>30 seconds), with SV runs (>5 beats but <30 seconds in a 24-hour ECG interval), and without SV runs (controls). During follow-up, those with baseline pAF received another 7-day Holter ECG to examine AF persistence.Results:A total of 254 of 281 initially included patients were analyzed (mean age 70.0 years, 45.3% female). Forty-three (16.9%) had AF-adm. A total of 211 received 7-day Holter ECG monitoring: 27 (12.8%) had pAF, 67 (31.8%) had SV runs, and 117 (55.5%) were controls. During a mean 3.7 years of follow-up, the SV runs group had more recurrent strokes (p = 0.04) and showed numerically more novel AF (12% vs 5%, p = 0.09) than the controls. Seventy-five percent of the patients with manifest pAF detected after cerebral ischemia still had AF during follow-up (50% paroxysmal, 50% persisting/permanent).Conclusions:Patients with cerebral ischemia and SV runs had more recurrent strokes and numerically more novel AF during follow-up and could benefit from further prolonged ECG monitoring. pAF detected after stroke is not a temporal phenomenon.

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Implantable loop recorder follow-up

European Heart Journal ◽

10.1093/eurheartj/ehab724.0318 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

J Pena Mellado ◽

R Macias ◽

L Tercedor ◽

M Alvarez Lopez

Keyword(s):

Head Trauma ◽

Type I ◽

Av Block ◽

Implantable Loop Recorder ◽

Ecg Monitoring ◽

Loop Recorder ◽

Tertiary Center ◽

Unexplained Syncope ◽

Baseline Characteristics

Abstract Introduction Long ambulatory ECG monitoring can be a useful component in the evaluation of the patient with unexplained syncope or syncope with suspected arrhythmic origin, as well as a sensitive tool for detecting asymptomatic spontaneous cardiac arrhythmias or conduction abnormalities in predisposed patients. Purpose To determine the diagnostic cost-effectiveness of the implantable loop recorder (ILR) in the origin of unexplained syncope in our center. Methods A retrospective observational study was carried out in a tertiary center, those patients with an ILR between August 2014 and March 2021 were included. Baseline characteristics of the population and their previous ECG, arrythmias detected during follow-up and pacemaker implant rate were evaluated. Results One hundred twenty-seven patients with a ILR were included (age 67 years, 49.6% males). Most often cause of ILR was unexplained syncope (90.6%) followed by monitoring after TAVI implant (3.9%). Normal LVEF (>50%) was present in 85.6%,and 75.6% had NYHA I functional class. 118 patients (92.9%) presented sinus rhythm at implant time, and 8 (6.3%) presented AF. 12.6% presented first degree atrioventricular (AV) block, 2 patients (1.6%) had presented previously Mobitz Type I AV block and one patient 2:1 block. Left bundle branch block (LBBB) was present in 13.4%,RBBB in 3.1%,LAFB in 9.4%, RBBB+LAFB in 11% and RBBB+LPFB in 2.4%. Median time of follow-up was 21 months. 3rd degree AV block was the most frequent arrhythmia detected (12.1%), followed by >3s pause (8%) and previously unknown AF (2.4%).The patients with syncope who suffered head trauma (33%) presented a higher rate of pacemaker (PCM) implant compared to those without head trauma: 31.6% vs 14.7%. In total,19.8% PCM rate implant during follow-up. No complications ILR related. Conclusion In conclusion, long home ECG monitoring with ILR is a powerful and helpful tool to find out or rule out potentially dangerous arrhythmias as cause of syncope, with no complications in our experience. FUNDunding Acknowledgement Type of funding sources: None. Baseline characteristics Arrhythmias detected during follow-up

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Abstract TP317: Utility and Cost of Inpatient Thrombophilia Testing in Ischemic Stroke Patients Aged 18-60

Stroke ◽

10.1161/str.51.suppl_1.tp317 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Effrosyni Apostolidou ◽

Priya Khatri ◽

Eric Thomas ◽

Sean Savitz ◽

Alicia Zha

Keyword(s):

Ischemic Stroke ◽

Cryptogenic Stroke ◽

Inpatient Setting ◽

Initial Hospital ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

One Year ◽

Care Costs ◽

Fvl Mutation

Introduction: Patients (pts) <60 years with ischemic stroke (IS) are commonly tested for thrombophilias (TP) due to the perception that there could be underlying hypercoagulable states. However, inherited TPs are largely not a risk factor for IS; and testing for acquired TPs in an acute inpatient setting may yield erroneous results that increase health care costs. We reviewed the frequency and cost of TP testing at our institution as part of a plan-do-study act cycle for improving the utilization of inpatient TP testing in young pts after IS. Methods: We performed a retrospective review of 18-60 year old pts admitted for IS to our comprehensive stroke center between 11/2016 and 7/2018. Pts discharged with a stroke etiology not attributed to large vessel (LV), small vessel (SV), or cardioembolic (CE) origin and the initial hospital TP testing monitored. Pts seen subsequently in clinic or later admissions in our system were monitored. Results: Of 1,162 pts, 104 without diagnosed LV/SV/CE etiologies were identified. At least one TP test was performed in 82 (79%) pts (Table 1). In 70 pts testing was done in the initial 24 hrs of hospitalization. One test abnormality was seen in 42 (51%) pts but anticoagulation was initiated in only one 1 patient at discharge. Forty-seven (45%) pts were followed in our outpatient clinic, with a mean follow up of 5 (0.2 – 24) months. TP was confirmed in 3 pts in clinic – two with heterozygous FVL mutation and one with known homozygous FVL mutation. The total charges of the initial inpatient testing is estimated to be as high as $222,150 for 82 patients. Conclusion: Frequent inpatient TP testing in young pts with cryptogenic stroke does not change management and can be costly to the hospital. Based on these results, we created a practice guideline to improve utilization of TP testing starting January 2019. A one year analysis of the effectiveness, safety, and cost for these changes is ongoing.

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Abstract WP264: Frequency of Hypercoagulability in Patients With Embolic Stroke of Undetermined Source and Patent Foramen Ovale

Stroke ◽

10.1161/str.51.suppl_1.wp264 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Michael Liu ◽

Srikant Rangaraju ◽

Alexander Duncan ◽

Samir Belagaje ◽

Trina Belair ◽

...

Keyword(s):

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Paradoxical Embolism ◽

Embolic Stroke ◽

Composite Outcome ◽

Foramen Ovale ◽

Primary Mechanism ◽

Detailed Evaluation ◽

D Dimer

Introduction: Patent foramen ovale (PFO) is more commonly found in patients with cryptogenic stroke and paradoxical embolism is commonly assumed to be the primary mechanism. Our objective was to determine the frequency of hypercoagulability in cryptogenic stroke patients and PFO. Methods: Consecutive patients with embolic stroke of undetermined source (ESUS) seen at the Emory Clinic from January 1, 2017 to June 30, 2019 who underwent echocardiogram with bubble study and markers of coagulation and hemostatic activation (MOCHA) testing (serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) were included; abnormal MOCHA was defined as ≥ 2 elevated markers. Venous thromboembolism, malignancy, other defined hypercoagulable state, and the composite outcome were assessed at routine follow-up and compared across groups based on PFO status. Results: Of 172 patients (mean age 63 ± 16 years, 60% female), 40 (23%) had a PFO. Compared to the PFO- group, the PFO+ group was younger (p=<0.001), less likely to have hypertension (p<0.001) and diabetes (p=0.011), and had a higher ROPE score (p=0.007) (Table 1). There was no difference in the frequency of abnormal MOCHA between groups and the composite outcome was less frequent in PFO+ versus PFO- patients (p=0.017). In the subgroup of patients <60 years old, there was no difference in the frequency of abnormal MOCHA and the composite outcome. Conclusion: Hypercoagulability as measured by MOCHA was not associated with the presence of PFO in ESUS patients. Based on our results, ESUS patients should undergo a detailed evaluation for alternative causes of stroke other than paradoxical embolism.

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Abstract P640: Incident Atrial Fibrillation and Cardiovascular Risk Increases in Patients With Increased Burden of Atrial Ectopy

Stroke ◽

10.1161/str.52.suppl_1.p640 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Michael N Sattin ◽

Zhe Li ◽

Marko Mrkobrada ◽

Erin I Spicer

Keyword(s):

Atrial Fibrillation ◽

Cardiovascular Events ◽

Univariate Analysis ◽

Composite Outcome ◽

Ecg Monitoring ◽

Reduced Ejection Fraction ◽

Final Sample ◽

Atrial Ectopy ◽

The Relationship

Introduction: Atrial fibrillation (AF) is a major risk factor for cerebral ischemia in North America. Atrial ectopy has been associated with incident AF and increased stroke risk on short-duration ECG monitoring. The objective of this study was to characterize the relationship between the burden of atrial ectopy with future AF, stroke, and cardiovascular events on prolonged ECG monitoring. Methods: A retrospective, observational study was conducted at a single centre enrolling patients >18 years old referred from TIA clinic. Data was collected from 7- and 14-day Holter monitor reports, patient charts, and cardiac investigations. The final sample included 1124 patients; a subgroup of 759 patients had echocardiograms. Univariate and multivariate logistic regression determined the odds ratio (OR) of developing the composite outcome (AF, TIA/stroke, ACS, death) or secondary outcomes (AF or TIA/stroke). Results: The population was high-risk with a mean CHA 2 DS 2 -VASc of 4.0 (±1.8); during 1-year of follow-up, the primary outcome occurred amongst 116 (10.3%) patients. Univariate analysis ORs are displayed in Table 1. There was a statistically significant relationship (p<0.001) between percentage of PACs and the composite outcome (OR 4.066), and AF (11.886) for patients with 2-5% PACs. PAC runs/day was significant if >5/day for AF (OR 5.989, p<0.01) and for the composite (OR 2.231, p<0.05). Long PAC runs (>30 beats) also had significant ORs for AF (2.849, p<0.01) and the composite (5.320, p<0.01). In the subgroup analysis, reduced ejection fraction had an OR of 2.172 (1.407-5.771) for the composite outcome, and atrial dilatation had an OR of 2.778 (1.390-5.551) for AF. Conclusions: Increased burden of atrial ectopy is associated with increased odds of developing AF and a composite of cardiovascular events. Patients with increased ectopy should be considered for further, future ECG monitoring and risk stratification with echocardiogram.

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