Atrial Fibrillation In Patients With Stroke Attributed to Large- or Small-Vessel Disease

Abstract

ImportanceThe STROKE AF study found that in patients with prior ischemic stroke attributed to large-artery atherosclerotic disease (LAD) or small-vessel occlusive disease (SVD), 12% developed AF over 1 year when monitored with an insertable cardiac monitor (ICM). The occurrence over subsequent years is unknown.ObjectivesTo compare the rates of AF detection through 3 years of follow-up between an ICM vs site-specific usual care in patients with prior ischemic stroke attributed to LAD or SVD.Design, Setting, and ParticipantsThis multicenter, randomized (1:1) clinical trial took place at 33 sites in the US with enrollment between April 2016 and July 2019 and 3-year follow-up through July 2022. Eligible patients were aged 60 years or older, or aged 50 to 59 years with at least 1 additional stroke risk factor and had an index ischemic stroke attributed to LAD or SVD within 10 days prior to ICM insertion. Of the 496 patients enrolled, 492 were randomized and 4 were excluded.InterventionsICM monitoring vs site-specific usual care.Main Outcomes and MeasuresThe prespecified long-term outcome of the trial was AF detection through study follow-up (up to 3 years). AF was defined as an episode lasting more than 30 seconds, adjudicated by an expert committee.ResultsIn total, 492 patients were randomized and included in the analyses (median [IQR] age, 66 [60-74] years; 307 men [62.4%] and 185 women [37.6%]), of whom 314 completed 3-year follow-up (63.8%). The incidence rate of AF at 3 years was 21.7% (46 patients) in the ICM group vs 2.4% (5 patients) in the control group (hazard ratio, 10.0; 95% CI, 4.0-25.2; P < .001).Conclusions and RelevancePatients with ischemic stroke attributed to LAD or SVD face an increasing risk of AF over time and most of the AF occurrences are not reliably detected by standard medical monitoring methods. One year of negative monitoring should not reassure clinicians that patients who have experienced stroke will not develop AF over the next 2 years.Trial RegistrationClinicalTrials.gov Identifier: NCT02700945

Incidence of stroke, subsequent clinical outcomes and health care resource utilization in people with type 2 diabetes: a real-world database study in France: “INSIST” study

“…Another potential explanation might be the potential under-estimation of cardiac arrhythmias due to the use of hospital discharge diagnosis codes to detect this outcome. The probability of atrial fibrillation following ischemic stroke has been demonstrated to be high, regardless of whether the stroke can be attributed to other non-cardioembolic causes such as large-artery atherosclerotic disease or small-vessel occlusive disease [ 30 – 32 ]. Given that atrial fibrillation increases the risk of ischemic stroke five-fold [ 33 ], the findings highlight the importance of accurate cardiac arrythmia evaluation and subsequent antithrombotic therapy in stroke patients with T2D.…”

Cardiocerebrovascular benefits of early rhythm control in patients with atrial fibrillation detected after stroke: a systematic review and meta-analysis

“…Conversely, stroke can also trigger the detection of AF, with approximately 1.5 million stroke survivors worldwide later being diagnosed with AF ( 3 ). Bernstein et al discovered that the rate of detecting AF in patients with a history of stroke is 21.7% within a 3-year period ( 4 ). Nevertheless, there is a noticeable absence of standardized treatment guidelines for patients with AFDAS ( 5 ).…”

What Do We Really Know About the Effect of Prolonged Heart Rhythm Monitoring After Stroke?

“…While the consideration of ILR screening for AF poststroke is in line with current guideline recommendations, 2,3 there is limited evidence that the increased AF detection leads to benefit on clinical outcomes (eg, strokes prevented). 6,7 The extrapolation of knowledge from clinically detected AF (eg, AF that is sustained, documented by standard noninvasive testing, or symptomatic) to SCAF (eg, silent arrhythmia detected with prolonged monitoring) may not be justified given the limited amount of randomized studies in patients with SCAF. In contrast to clinical AF, OAC for SCAF may not confer a net benefit for the majority of patients.…”