Duration of Implantable Cardiac Monitoring and Detection of Atrial Fibrillation in Ischemic Stroke Patients: A Systematic Review and Meta-Analysis

Abstract

Background and PurposeCurrent guidelines do not provide firm directions on atrial fibrillation (AF) screening after ischemic stroke (IS). We sought to investigate the association of implantable cardiac monitoring (ICM) duration with the yield of AF detection in IS patients. MethodsWe included studies reporting AF detection rates by ICM in IS patients with negative initial AF screening. We excluded studies reporting prolonged cardiac monitoring with devices other than ICM, not providing AF detection rates or monitoring duration, and reporting overlapping data for the same population. The random-effects model was used for all pooled estimates and meta-regression analyses. ResultsWe included 28 studies (4,531 patients, mean age 65 years). In meta-regression analyses, the proportion of AF detection by ICM was independently associated with monitoring duration (coefficient=0.015; 95% confidence interval [CI], 0.005 to 0.024) and mean patient age (coefficient=0.009; 95% CI, 0.003 to 0.015). No associations were detected with other patient characteristics, including IS subtype (cryptogenic vs. embolic stroke of undetermined source) or time from IS onset to CM implantation. In subgroup analyses, significant differences (P<0.001) in the AF detection rates were found for ICM duration (<6 months: 5% [95% CI, 3% to 6%]; ≥6 and ≤12 months: 21% [95% CI, 16% to 25%]; >12 and ≤24 months: 26% [95% CI, 22% to 31%]; >24 months: 34% [95% CI, 29% to 39%]). ConclusionsExtended duration of ICM monitoring and increased patient age are factors that substantially increase AF detection in IS patients with initial negative AF screening.

Implantable Cardiac Monitoring in the Secondary Prevention of Cryptogenic Stroke

“…The independent association of ICM duration with the probability of PAF detection was also recently highlighted by a recent systematic review and metaregression analysis of studies reporting on the incidence of PAF with different cardiac monitoring devices after an acute ischemic stroke or TIA. 19 This meta-analysis reported significant differences in the AF detection rates with respect to ICM duration (< 6 months: 5% [95% CI = 3%-6%]; ≥ 6 and ≤ 12 months: 21% [95% CI = 16%-25%]; > 12 and ≤ 24 months: 26% [95% CI = 22%-31%]; and > 24 months: 34% [95% CI = 29%-39%]). 19 We found numerically considerable differences in the median durations of PAF detection for patients receiving ICM compared to conventional cardiac monitoring (10 minutes vs 22 minutes) and in the percentages of patients with PAF duration ≤ 6 minutes between the 2 groups (34.6% vs 21.4%).…”

“…19 This meta-analysis reported significant differences in the AF detection rates with respect to ICM duration (< 6 months: 5% [95% CI = 3%-6%]; ≥ 6 and ≤ 12 months: 21% [95% CI = 16%-25%]; > 12 and ≤ 24 months: 26% [95% CI = 22%-31%]; and > 24 months: 34% [95% CI = 29%-39%]). 19 We found numerically considerable differences in the median durations of PAF detection for patients receiving ICM compared to conventional cardiac monitoring (10 minutes vs 22 minutes) and in the percentages of patients with PAF duration ≤ 6 minutes between the 2 groups (34.6% vs 21.4%). Even though these differences were not found to be statistically significant, due to the limited patient sample size, the increased use of anticoagulants in patients with ICM resulted in significantly lower incidence of stroke recurrence, posing an additional argument against the different clinical relevance of ICM detected versus conventional cardiac monitoring detected PAF.…”

Burden of Oral Anticoagulation in Embolic Stroke of Undetermined Source without Atrial Fibrillation

“…where one-third of continuously monitored ESUS patients had AF.7 ,27 The second hypothesis driving the concept of anticoagulation for all ESUS patients was the debate on whether AF is the only or main culprit behind CS/ESUS driven by lack of knowledge of the mechanisms underpinning the relationship between AF and stroke, 28 and the role of the left atrial appendage (LAA) as a site of thrombus formation 29 , especially in CS. Moreover, several other non-AF mechanisms of stroke potentially bene ting from anticoagulation had been proposed including stasis due to an atrial cardiopathy 27 and artery-to-artery embolism. 30,31 Pre-DOAC-era studies…”

Software‐based analysis of 1‐hour Holter ECG to select for prolonged ECG monitoring after stroke

“…Or does the resulting oral anticoagulation in these patients reduce recurrent stroke? A recent meta‐analysis demonstrated a reduction of recurrent cerebral ischemic events by ECG monitoring after stroke, 30 arguing to anticoagulate stroke patients with pAF detected by prolonged monitoring. Nonetheless, a randomized trial demonstrating a reduction in ischemic stroke rates by means of prolonged ECG monitoring as primary outcome is needed to establish the necessity of prolonged monitoring as effective stroke prevention in clinical practice.…”