A meta-analysis of extended ECG monitoring in detection of atrial fibrillation in patients with cryptogenic stroke

Jiang, Haowen; Tan, Shyn Yi; Wang, Jeremy King; Li, Jiaqi; Tu, Tian Ming; Tan, Vern Hsen; Yeo, Colin

doi:10.1136/openhrt-2022-002081

Cited by 9 publications

(9 citation statements)

References 43 publications

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“…There is a clinical significance of AF/AFL detection in CS patients because it has an impact on secondary stroke prevention, which is possibly associated with higher anticoagulation incidence, although controversial [ 6 , 7 ]. The AF/AFL detection rate in our cohort was similar or relatively higher than in previous studies, which showed that most AF detections by ILR occurred during the first few months [ 8 – 12 ]; however, the cumulative incidence of AF detection continued to increase over a year, albeit slowly. Our study results were also consistent with these findings, but the most distinct observation from our study population was that the interval from the index stroke to ILR implant was remarkably long [ 3 , 4 , 9 – 13 ].…”

Section: Discussionsupporting

confidence: 76%

Impact of an expanded reimbursement policy on utilization of implantable loop recorders in patients with cryptogenic stroke in Korea

Gwag,

Ko,

Jin

2024

Korean J Intern Med

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Background/Aims: The reimbursement policy for cryptogenic stroke (CS) was expanded in November 2018 from recurrent strokes to the first stroke episode. No reports have demonstrated whether this policy change has affected trends in implantable loop recorder (ILR) utilization.Methods: We identified patients who received an ILR implant using the Korea Health Insurance Review and Assessment Service database between July 2016 and October 2021. Patients meeting all the following criteria were considered to have CS indication: 1) prior stroke history, 2) no previous history of atrial fibrillation or flutter (AF/AFL), and 3) no maintenance of oral anticoagulant for ≥4 weeks within a year before ILR implant. AF/AFL diagnosed within 3 years after ILR implant or before ILR removal was considered ILR-driven.Results: Among 3,056 patients, 1,001 (32.8%) had CS indications. The total ILR implant number gradually increased for both CS and non-CS indications and the number of CS indication significantly increased after implementing the expanded reimbursement policy. The detection rate for AF/AFL was 26.3% in CS patients over 3 years, which was significantly higher in patients implanted with an ILR within 2 months after stroke than those implanted later.Conclusions: The expanded coverage policy for CS had a significant impact on the number of ILR implantation for CS indication. The diagnostic yield of ILR for AF/AFL detection seems better when ILR is implanted within 2 months than later. Further investigation is needed to demonstrate other clinical benefits and the optimal ILR implantation timing.

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Section: Discussionsupporting

confidence: 76%

Impact of an expanded reimbursement policy on utilization of implantable loop recorders in patients with cryptogenic stroke in Korea

Gwag,

Ko,

Jin

2024

Korean J Intern Med

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“…Our findings are in line with previous work that have similarly highlighted the benefits of utilizing multiple cardiac monitoring strategies to optimize nAF detection. 7,22 Finally, our results further suggest that a minimum monitoring period of 1 year should be considered in suitable ESUS patients to detect nAF after ischaemic stroke and TIA.…”

Section: Discussionmentioning

confidence: 57%

Identifying the optimal time period for detection of atrial fibrillation after ischaemic stroke and TIA: An updated systematic review and meta-analysis of randomized control trials

Thakur,

Alsinbili,

Chattopadhyay

et al. 2023

International Journal of Stroke

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Background Atrial fibrillation (AF) is a major risk-factor for ischaemic stroke (IS) and transient ischaemic attack (TIA). The timely detection of first-diagnosed AF (nAF), and subsequently commencing anticoagulation, is crucial to prevent recurrence, however, the optimal timing and duration of rhythm monitoring to detect nAF remains unclear. Aims We searched MEDLINE, PubMed, Cochrane database, and Google Scholar to undertake a systematic review and meta-analysis of randomised controlled trials (RCT) between 2012-2023 investigating nAF detection after IS and TIA. Outcome measures were overall detection of nAF (control; (usual care) compared to intervention; (continuous cardiac monitoring >72h)) and the time period in which nAF detection is highest (0-14 days, 15-90 days, 91-180 days or 181-365 days). A random-effects model with generic inverse variance weights was used to pool the most adjusted effect measure from each trial. Summary of review A total of eight RCTs investigated rhythm monitoring after IS, totaling 5820 patients. The meta-analysis of the studies suggested that continuous cardiac monitoring was associated with a pooled odds ratio of 3.81 (95% CI 2.14 to 6.77), compared to usual care (control), for nAF detection. In the time period analysis, the odds ratio for nAF detection at 0-14 days, 15-90 days, 91-180 days, 181-365 days were 1.79 (1.24-2.58); 2.01 (0.63-6.37); 0.98 (0.16-5.90) and 2.92 (1.30-6.56) respectively. Conclusion There is an almost 4-fold increase in nAF detection with continuous cardiac monitoring, compared to usual care. The results also demonstrate two statistically significant time periods in nAF detection; at 0-14 days and 6-12 months following monitoring commencement. These data support the utilisation of different monitoring methods to cover both time periods and a minimum of 1 year of monitoring to maximise nAF detection in patients after IS and TIA.

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“…The longer scanning time of ICMs leads to increased rates of AF paroxysms, but the causal relationship of the detected AF paroxysms with IS is still unclear, as is the optimal screening strategy and scanning duration [ 19 , 80 , 83 ]. However, there is accumulating evidence that initiating ECG screening early after IS is more efficacious compared to later initiated screening, and that certain screening methods, including chest belt ECG, may be more effective in the early stage of screening [ 84 ]. Moreover, there is a relatively strong consensus view on the benefits and cost-efficacy of the staged AF screening strategy after cryptogenic IS [ 85 ].…”

Section: Screeningmentioning

confidence: 99%

Stroke in Patients with Atrial Fibrillation: Epidemiology, Screening, and Prognosis

Suomalainen,

Martinez-Majander,

Broman

et al. 2023

JCM

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Atrial fibrillation (AF) is the most common sustained arrythmia and one of the strongest risk factors and causal mechanisms of ischemic stroke (IS). Acute IS due to AF tends to be more severe than with other etiology of IS and patients with treated AF have reported to experience worse outcomes after endovascular treatment compared with patients without AF. As cardioembolism accounts for more than a fifth of ISs and the risk of future stroke can be mitigated with effective anticoagulation, which has been shown to be effective and safe in patients with paroxysmal or sustained AF, the screening of patients with cryptogenic IS (CIS) for AF is paramount. Embolic stroke of undetermined source (ESUS) is a subtype of CIS with a high likelihood of cardioembolism. The European Stroke Organization and European Society of Cardiology guidelines recommend at least 72 h of screening when AF is suspected. The longer the screening and the earlier the time point after acute IS, the more likely the AF paroxysm is found. Several methods are available for short-term screening of AF, including in-hospital monitoring and wearable electrocardiogram recorders for home monitoring. Implantable loop monitors provide an effective long-term method to screen patients with high risk of AF after IS and artificial intelligence and convolutional neural networks may enhance the efficacy of AF screening in the future. Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in both primary and secondary prevention of IS in AF patients. Recent data from the randomized controlled trials (RCT) also suggest that early initiation of DOAC treatment after acute IS is safe compared to later initiation. Anticoagulation treatment may still predispose for intracranial bleeding, particularly among patients with prior cerebrovascular events. Left atrial appendix closure offers an optional treatment choice for patients with prior intracranial hemorrhage and may offer an alternative to oral anticoagulation even for patients with IS, but these indications await validation in ongoing RCTs. There are still controversies related to the association of found AF paroxysms in CIS patients with prolonged screening, pertaining to the optimal duration of screening and screening strategies with prolonged monitoring techniques in patients with ESUS. In this review, we summarize the current knowledge of epidemiology, screening, and prognosis in AF patients with stroke.

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A meta-analysis of extended ECG monitoring in detection of atrial fibrillation in patients with cryptogenic stroke

Cited by 9 publications

References 43 publications

Impact of an expanded reimbursement policy on utilization of implantable loop recorders in patients with cryptogenic stroke in Korea

Impact of an expanded reimbursement policy on utilization of implantable loop recorders in patients with cryptogenic stroke in Korea

Identifying the optimal time period for detection of atrial fibrillation after ischaemic stroke and TIA: An updated systematic review and meta-analysis of randomized control trials

Stroke in Patients with Atrial Fibrillation: Epidemiology, Screening, and Prognosis

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