Atrial Fibrillation After Ischemic Stroke Detected by Chest Strap-Style 7-Day Holter Monitoring and the Risk Predictors: EDUCATE-ESUS

Abstract

This study aimed to investigate the diagnostic yield of 7-day Holter monitoring for detecting covert atrial fibrillation (AF) in patients with recent embolic stroke of undetermined source (ESUS) and to identify the preentry screening biomarkers that had significant associations with later detection of AF (clinicaltrials.gov. NCT02801708).Methods: A total of 206 patients who have recent ESUS without previously documented AF underwent Holter electrocardiography using a chest strap-style monitor. External validation of biomarkers predictive of AF was performed using 83 patients with ESUS who were implanted with i nsertable cardiac monitors.Results: T he 7-day Holter monitoring started at a median of 13 days after the onset of stroke. AF was detected in 14 patients, and three of these showed a single AF episode lasting 2 min. The median time delay to the first documented AF was 50 h. Each of serum brain natriuretic peptide ≥ 66.0 pg/mL (adjusted odds ratio 5.23), atrial premature contractions (APCs) ≥ 345 beats (3.80), and APC short runs ≥ 13 (5.74) on 24-h Holter prior to the 7-day Holter showed a significant association with detection of AF, independent of age and physiological findings in this derivation c ohort, and all of these showed a significant association in the validation cohort (adjusted odds ratio 6.59, 7.87, and 6.16, respectively). Conclusions:In recent ESUS patients, the detection rate of AF using the 7-day Holter monitoring was 6.8% (95% CI 4.1%-11.1%). Brain natriuretic peptide, APC count, and APC short runs in the standard clinical workup seemed to be predictors of covert AF.term "embolic stroke of undetermined source (ESUS)" has been proposed as a new clinical entity to refine its definition,. Covert atrial fibrillation (AF) is thought to be relatively common among potential embolic sources of ESUS.

Premature atrial complexes can predict atrial fibrillation in ischemic stroke patients: A systematic review and meta‐analysis

“…Forty additional articles were excluded: 22 were conference abstracts, two were reviews, 14 did not fulfill the inclusion criteria, and two did not provide HR, OR, or RR. Therefore, 12 eligible studies 3–7,11–17 were finally included in this meta‐analysis (Figure 1).…”

“…Among the 12 eligible cohort studies, seven were prospective 4–6,11,12,16,17 and the remaining five were retrospective 3,7,13–15 (Table 1). A total of 2340 ischemic stroke patients without documented AF were included, with a mean age of 65.9 years.…”

“…AF was detected in 346 cases during follow‐ups. Cryptogenic stroke patients were enrolled in eight studies 3–7,14,16,17 . Regarding the definition of PACs and detection methods, two studies were PAC presence on ECG, 3,14 1 was PAC presence on Holter, 16 1 was > 0−1 PAC/10 s on ECG 5 .…”

“…Regarding the definition of PACs and detection methods, two studies were PAC presence on ECG, 3,14 1 was PAC presence on Holter, 16 1 was > 0−1 PAC/10 s on ECG 5 . Frequent PACs were defined as >70 PACs/24 h on Holter or implantable loop recorders in eight studies, 4,6,7,11–13,15,17 which resulted from a percentile of PAC‐count in five studies, 4,6,7,11,15 from the receiver operating characteristic curve in two studies, 13,17 from a previous study result 11 in 1 study 12 . The quality scores were six or more evaluated by NOS, indicating a high quality of included studies (Table S2).…”

“…Firstly, we performed the subgroup analysis based on the follow‐up period. Five studies conducted a short‐term follow‐up (≤ 1 month), 3,13–15,17 in which AF was detected in 99 of 839 stroke patients. Frequent PACs were associated with a significant increased incidence of paroxysmal AF (pooled OR: 6.18, 95% CI: 3.23‐11.83, with I 2 of 0) (Figure 3A).…”