Insertable cardiac monitors after cryptogenic stroke – a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation

Poli, Sven; Diedler, Jennifer; Härtig, Florian; Götz, Nina; Bauer, Axel; Sachse, T.; Müller, Karin; Müller, Iris; Stimpfle, Fabian; Duckheim, Martin; Steeg, M. van der; Eick, Christian; Schreieck, Jürgen; Gawaz, Meinrad; Ziemann, Ulf; Zuern, Christine S.

doi:10.1111/ene.12843

Cited by 92 publications

(94 citation statements)

References 31 publications

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“…In addition, MRI is able to identify atrial cardio(myo)pathy 28 -a so far neglected source of cardiac embolism. Furthermore, cvMRI is also able to precisely characterize left atrial enlargement 17 independently associated with AF detection by an insertable cardiac monitor according to a recent study enrolling patients with cryptogenic stroke 29 -and the morphology of the left atrial appendage, another potential source of embolism (independent of AF). Because the exclusion of cardiac sources of stroke by using either TTE or TEE is a prerequisite of the present ESUS (Embolic Stroke of Undetermined Source) classification, 3 cardiac (magnetic resonance) imaging in the acute phase of stroke will be valuable even in case of a benefit of long-term non-vitamin K dependent oral anticoagulant therapy in ESUS patients.…”

Section: Discussionmentioning

confidence: 99%

Feasibility and Diagnostic Value of Cardiovascular Magnetic Resonance Imaging After Acute Ischemic Stroke of Undetermined Origin

Hæusler

Wollboldt

Bentheim

et al. 2017

Stroke

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E tiologic work-up is essential in patients with acute ischemic stroke to optimize secondary stroke prevention. According to international guidelines, state-of-the-art diagnostic work-up includes brain imaging, ultrasound of brainsupplying arteries, echocardiography, ECG monitoring, and distinct blood tests.1,2 However, stroke etiology remains undetermined (cryptogenic) in about 25% of all acute ischemic stroke patients. 3 Apart from nonpermanent atrial fibrillation (AF), 4 ventricular noncompaction, left atrial or ventricular thrombi, mitral or aortic valve stenosis, and ulcerated aortic arch atherosclerotic plaques are associated with a moderate to high embolic stroke risk and were found in a substantial part Background and Purpose-Etiology of acute ischemic stroke remains undetermined (cryptogenic) in about 25% of patients after state-of-the-art diagnostic work-up. Methods-One-hundred and three patients with magnetic resonance imaging (MRI)-proven acute ischemic stroke of undetermined origin were prospectively enrolled and underwent 3-T cardiac MRI and magnetic resonance angiography of the aortic arch in addition to state-of-the-art diagnostic work-up, including transesophageal echocardiography (TEE). We analyzed the feasibility, diagnostic accuracy, and added value of cardiovascular MRI (cvMRI) compared with TEE for detecting sources of stroke. Despite interstudy variations on the definition and prevalence of (potential) embolic sources, current guidelines recommend diagnostic echocardiography in stroke patients. 2Although noninvasive transthoracic echocardiography (TTE) is easy to use, semi-invasive transesophageal echocardiography (TEE) is typically needed to visualize the left atrium, left atrial appendage, atrial shunts, and the aortic arch-all of them potential sources of embolism.6 Serious complications during TEE rarely occur.7 However, required preprocedural fasting, periprocedural conscious sedation, and the demand of highly skilled personnel limit its availability and cause in-hospital delays. 8 In consequence, TEE is not routinely performed in (cryptogenic) stroke patients, even in high-income countries.9 Subsequently, assessment of potential embolic sources of ischemic stroke is often inappropriate in clinical practice. Although cardiac computed tomography could add information about stroke etiology, 10 the main disadvantage of this approach is the exposure to radiation. Cardiac magnetic resonance imaging (MRI) has been increasingly often implemented in the clinical diagnostic workflow of various cardiac diseases over the past 10 years and allows for accurate biventricular functional analysis and tissue characterization. Cardiac MRI is now considered the gold standard to assess cardiac tumors, myocarditis, cardiomyopathies, and subclinical coronary heart disease. 11,12 In addition, cardiac MRI has demonstrated feasibility of detecting atrial or ventricular thrombi, 13 aortic atherosclerotic plaques, 14,15 or left atrial enlargement. 16,17 Moreover, cardiac MRI is superior to echocardiography on d...

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Section: Discussionmentioning

confidence: 99%

Feasibility and Diagnostic Value of Cardiovascular Magnetic Resonance Imaging After Acute Ischemic Stroke of Undetermined Origin

Hæusler

Wollboldt

Bentheim

et al. 2017

Stroke

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“…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.…”

Section: Discussionmentioning

confidence: 99%

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

Uphaus

Grings

Gröschel

et al. 2017

Euro J of Neurology

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Background and purposeProlonged electrocardiogram (ECG) monitoring after ischaemic stroke increases the diagnostic yield of paroxysmal atrial fibrillation (pAF). In order to facilitate the additional workload involved in ECG analysis due to prolonged monitoring times, we investigated the effectiveness of pAF detection with an automated software algorithm (SA) in comparison to the routine staff‐based analysis (RA) during standard stroke‐unit care. Therefore, patients with acute ischaemic stroke or transitory ischaemic attack presenting with sinus rhythmus on the admission ECG and no history of atrial fibrillation were prospectively included.MethodsA 24‐h Holter ECG assessment was performed using either RA based on a computer‐aided evaluation and subsequent review by a cardiologist or a commercially available automated SA. In the case of discordant results concerning the occurrence of pAF between the two methods, the data underwent an independent external rating.ResultsOf 809 prospectively enrolled patients, 580 patients fulfilled the inclusion criteria. pAF was ultimately diagnosed in 3.3% of the cohort (19 patients). SA and RA correctly diagnosed pAF in 17 patients resulting in a comparable diagnostic effectiveness of the analysis methods (sensitivity: SA 89.5% vs. RA 89.5%; specificity: SA 99.3% vs. RA 99.1%; κ, 0.686; P < 0.001; 95% confidence interval, 0.525–0.847). RA revealed clinically relevant ECG abnormalities in an additional seven patients.ConclusionsAlthough it should not completely replace RA, SA‐based evaluation of Holter ECG reaches a high diagnostic effectiveness for the detection of pAF and can be used for a rapid and resource‐saving analysis of ECG data to deal with prolonged monitoring times.

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“…A reason for the missing association between imaging and stroke etiology might be based on the efficacy of cardiac monitoring (CRYSTAL-AF trial) or length of monitoring (Find-AF trial). In this respect, Poli et al were able to show that rhythm monitoring by a new event recorder (Medtronic Linq instead of XT device) and preselection of patients by the means of echocardiographic or indirect electrophysiological signs for underlying AF in cryptogenic stroke patients can be much more efficient with detection rates of AF up to 31% after 6 months of monitoring [16]. Therefore, the proportion of patients with ESUS and AF might be underestimated; AF patients could have been misclassified to the non-AF group in our study and the results of the association analyses would have been biased towards unity.…”

Section: Discussionmentioning

confidence: 99%

Association between Embolic Stroke Patterns, ESUS Etiology, and New Diagnosis of Atrial Fibrillation: A Secondary Data Analysis of the Find-AF Trial

Maier

Schregel

Karch

et al. 2017

Stroke Research and Treatment

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Background. Atrial fibrillation (AF) is an important cause of embolic stroke of undetermined source (ESUS). Imaging-patterns like multiple infarcts, simultaneous involvement of different circulations, infarcts of different ages, and isolated cortical infarcts are likely to indicate cardioembolic stroke. The aim of our study was to evaluate the association between embolic stroke patterns, ESUS, and the new diagnosis of AF. Methods. Stroke etiology and imaging characteristics from patients included in the Find-AF study were obtained. Embolic stroke patterns in CT- or MR-imaging were correlated with the diagnosis of ESUS as well as the short- (on baseline ECG and during 7-day Holter) and long-term (12-month follow-up) diagnosis of AF. Results. From 281 patients included in the Find-AF study, 127 (45.2%) patients with ischemic lesions detected in CT or MRI were included. 26 (20.5%) of these patients had ESUS. At least one embolic stroke pattern was detected in 67 (52.7%) patients. Embolic stroke patterns were not associated with ESUS (OR 1.57, 0.65–3.79, p = 0.317), the short-term (OR 0.64, 0.26–1.58, p = 0.327) or long-term diagnosis of AF (OR 0.72, 0.31–1.68, p = 0.448). Conclusions. This secondary data analysis of the Find-AF study could not provide evidence for an association between embolic stroke patterns, ESUS, and the new diagnosis of AF.

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Insertable cardiac monitors after cryptogenic stroke – a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation

Abstract: The detection rate of AF is one-third after 1 year if candidates for an ICM after cryptogenic IS/TIA are selected by AF risk factors. LA dilation and atrial runs independently predict AF.

Cited by 92 publications

References 31 publications

Feasibility and Diagnostic Value of Cardiovascular Magnetic Resonance Imaging After Acute Ischemic Stroke of Undetermined Origin

Feasibility and Diagnostic Value of Cardiovascular Magnetic Resonance Imaging After Acute Ischemic Stroke of Undetermined Origin

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

Association between Embolic Stroke Patterns, ESUS Etiology, and New Diagnosis of Atrial Fibrillation: A Secondary Data Analysis of the Find-AF Trial

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