Extended Electrocardiographic Poincare Analysis (EPA) for Better Identification of Patients with Paroxysmal Atrial Fibrillation

Abstract

Background: Atrial fibrillation (AF) -be it permanent or paroxysmal -is the most frequent and most effectively treatable cause of stroke. However, when paroxysmal, even electrocardiography for 24 hours (24h-ECG) misses AF in more than 50% of cases. We assessed whether extended Poincaré analysis of ECG R-R intervals (EPA) can help to identify electrocardiographic remodeling suggestive of paroxysmal AF (PAF). Methods:Twenty-nine patients with previously diagnosed PAF were re-assessed by 24h-ECG using conventional analysis and EPA based on a previously trained algorithm considering among other ratios of R-R interval duration, number of premature atrial complexes, approximate entropy, and standard deviation of Poincaré plots-axes. 24h-ECG from 21 healthy subjects without a history of AF served as negative, and 9 patients with permanent AF as positive controls.Results: PAF during 24h-ECG was detected in 4 out of 29 (14%) patients with a history of PAF by conventional analysis. EPA classified ECGs of these and 22 additional patients with a history of PAF, i.e. a total 90%, as suggestive of PAF. All patients with permanent AF were identified by both tools. EPA additionally classified the ECG in 4 out of 21 control subjects as suggestive of PAF.Conclusions: Extended Poincaré analysis in patients with a history of PAF is more sensitive to electrocardiographic abnormalities than is conventional 24h-ECG analysis. These findings warrant prospective studies of EPA in patients with a high likelihood of PAF, i.e. with stroke of undetermined origin.

Continuous Stroke Unit Electrocardiographic Monitoring Versus 24-Hour Holter Electrocardiography for Detection of Paroxysmal Atrial Fibrillation After Stroke

“…To detect episodes of AF, the software performs a time series analysis of multiple mathematical parameters that are typical for an absolute arrhythmia during AF. 30 Based on this analysis, the system creates a report on whether episodes of AF are present. In all cases in which the software reported AF, ECG source data were reviewed in detail to confirm or falsify these reports by 2 investigators (T.R., C.R.).…”

“…16,17 Continuous ECG monitoring (CEM) may help to recognize pxAF. 27,28 An automated analysis of ECG data to reveal pxAF 29,30 could further increase detection rates. However, the diagnostic value of CEM has not been appropriately studied, particularly not in comparison to the more widely used 24-hour Holter ECG.…”

Electrocardiographic RR Interval Dynamic Analysis to Identify Acute Stroke Patients at High Risk for Atrial Fibrillation Episodes During Stroke Unit Admission

“…CCM ECG tracks were sent via a secure internet connection to the SRA server (Apoplex Medical Technologies, Pirmasens, Germany) for the assessment of RR interval dynamics calculated on overall 48-h recordings. The details of SRA data processing have been previously described [ 8 , 9 ]. Briefly, the AF risk is associated with the presence of premature atrial complexes, atrial tachycardia, and other ectopic activities.…”

“…SRA clinic is a telemedicine service based upon RR interval dynamic analysis providing automated AF detection for SU patients [ 7 ]. The stroke risk analysis (SRA) algorithm had been demonstrated [ 8 , 9 ] able to identify abnormalities suggestive of increased PAF risk in patients with a previously diagnosed PAF but at sinus rhythm during the analysis with a 60% sensitivity and 99% specificity. Therefore, the SRA algorithm may be used to identify those acute stroke patients at higher risk for forthcoming PAF episodes.…”

Continuous ECG Monitoring for Tracking Down Atrial Fibrillation after Stroke: Holter or Automated Analysis Strategy?

“…Based on CEM data, SRAclinic identified QRS complexes with atrial origin and generated a list of R-R intervals. For each hour of CEM data, heart beat dynamic analysis was performed by an SRAclinic algorithm to generate an AF risk score based on nonlinear parameters of time series analysis [8,10,11,12,13,14]. Daily for each hour, the SRAclinic analysis report contained graphic representation of R-R intervals (Lorenz plots) and the level of AF risk score: sinus rhythm (risk 0), other cardiac arrhythmia (risk 1), atrial arrhythmia (risk 2), significant indication for paroxysmal AF (risk 3), and significant indication for acute AF (risk 4).…”