Enhanced Detection of Paroxysmal Atrial Fibrillation by Early and Prolonged Continuous Holter Monitoring in Patients With Cerebral Ischemia Presenting in Sinus Rhythm

Abstract

Background and Purpose-Diagnosis of paroxysmal atrial fibrillation is difficult but highly relevant in patients presenting withcerebral ischemia yet free from atrial fibrillation on admission. Early initiation and prolongation of continuous Holter monitoring may improve diagnostic yield compared with the standard of care including a 24-hour Holter recording. Methods-In the observational Find-AF trial (ISRCTN 46104198), consecutive patients presenting with symptoms of cerebral ischemia were included. Patients free from atrial fibrillation at presentation received 7-day Holter monitoring. Results-Two hundred eighty-one patients were prospectively included. Forty-four (15.7%) had atrial fibrillation documented by routine electrocardiogram on admission. All remaining patients received Holter monitors at a median of 5.5 hours after presentation. In those 224 patients who received Holter monitors but had no previously known paroxysmal atrial fibrillation, the detection rate with early and prolonged (7 days) Holter monitoring (12.5%) was significantly higher than for any 24-hour (mean of 7 intervals: 4.8%, Pϭ0.015) or any 48-hour monitoring interval (mean of 6 intervals: 6.4%, Pϭ0.023). Of those 28 patients with new atrial fibrillation on Holter monitoring, 15 (6.7%) had been discharged without therapeutic anticoagulation after routine clinical care (ie, with data from 24-hour Holter monitoring only). Detection rates were 43.8% or 6.3% for short supraventricular runs of Ն10 beats or prolonged episodes (Ͼ5 hours) of atrial fibrillation, respectively. Diagnostic yield appeared to be only slightly and not significantly increased during the first 3 days after the index event. Conclusions-Prolongation of Holter monitoring in patients with symptoms of cerebral ischemic events increases the rate of detection of paroxysmal atrial fibrillation up to Day 7, leading to a relevant change in therapy in a substantial number of patients. Early initiation of monitoring does not appear to be crucial. Hence, prolonged Holter monitoring (Ն7 days) should be considered for all patients with unexplained cerebral ischemia. (Stroke. 2010;41:2884-2888.)

Automatic detection of paroxysmal atrial fibrillation in patients with ischaemic stroke: better than routine diagnostic workup?

“…Because of this remarkable secondary preventive effect, recent studies have focused on an increased diagnostic yield of ECG monitoring. The authors of observational studies 1, 6, 7, 12, 13 and randomized trials 8, 14 achieved higher detection rates of pAF by simply prolonging monitoring times. Nevertheless, the analysis of prolonged monitoring data is costly in terms of time and resources, and therefore difficult to implement in clinical practice.…”

“…and R.W.) with experience in cardiac electrophysiology and conduct of randomized trials 7, 8. The diagnostic workup of ECG data is depicted in Fig.…”

A Structured Reading Algorithm Improves Telemetric Detection of Atrial Fibrillation After Acute Ischemic Stroke

“…11,20,21 Therefore, valid data on the sensitivity of monitoring are sparse. 22 In the current investigation, continuous inpatient monitoring for a median of 75.5 hours did not reveal any episodes of AF in two thirds of patients with previously documented AF but negative baseline ECG.…”

Prevention of Cardioembolic Stroke

“…In such patients with a high degree of clinical suspicion for arrhythmia, a 12-lead electrocardiogram, inpatient telemetry, or outpatient Holter monitor [10] or event recorder may be necessary to capture intermittent paroxysmal AF or sick sinus syndrome. Prolonged outpatient Holter monitoring up to 7 days can also be considered for patients with unexplained cerebral ischemia, which had a higher yield of occult AF detection compared to 24-h or 28-h Holter monitoring (12.5% compared with 4-6%) [11]. The key to preventing cardioembolic stroke is early recognition of risk factors before an actual stroke occurs.…”