Potential Cost-Effectiveness of Ambulatory Cardiac Rhythm Monitoring After Cryptogenic Stroke

Abstract

Background and Purpose-Prolonged ambulatory ECG monitoring after cryptogenic stroke improves detection of covert atrial fibrillation, but its long-term cost-effectiveness is uncertain. Methods-We estimated the cost-effectiveness of noninvasive ECG monitoring in patients aged ≥55 years after a recent cryptogenic stroke and negative 24-hour ECG. A Markov model used observed rates of atrial fibrillation detection and anticoagulation from a randomized controlled trial (EMBRACE) and the published literature to predict lifetime costs and effectiveness (ischemic strokes, hemorrhages, life-years, and quality-adjusted life-years [QALYs]) for 30-day ECG (primary analysis) and 7-day or 14-day ECG (secondary analysis), when compared with a repeat 24-hour ECG. Results-Prolonged ECG monitoring (7, 14, or 30 days) was predicted to prevent more ischemic strokes, decrease mortality, and improve QALYs. If anticoagulation reduced stroke risk by 50%, 30-day ECG (at a cost of USD $447) would be highly cost-effective ($2000 per QALY gained) for patients with a 4.5% annual ischemic stroke recurrence risk. Costeffectiveness was sensitive to stroke recurrence risk and anticoagulant effectiveness, which remain uncertain, especially at higher costs of monitoring. Shorter duration (7 or 14 days) monitoring was cost saving and more effective than an additional 24-hour ECG; its cost-effectiveness was less sensitive to changes in ischemic stroke risk and treatment effect. Conclusions-After a cryptogenic stroke, 30-day ECG monitoring is likely cost-effective for preventing recurrent strokes; 14-day monitoring is an attractive value alternative, especially for lower risk patients. These results strengthen emerging recommendations for prolonged ECG monitoring in secondary stroke prevention. Cost-effectiveness in practice will depend on careful patient selection.

Screening for Atrial Fibrillation

“…Post-stroke ECG monitoring is likely costeffective. 74,79 However, RCTs have not been powered to assess the effect of prolonged ECG monitoring on stroke or mortality.…”

Health Economic Evaluations of Digital Health Interventions for Secondary Prevention in Stroke Patients: A Systematic Review

“…Eight articles were excluded mainly, but not exclusively, because they did not report on health economic outcome parameters [12, 13, 14, 15, 16, 17, 18, 19]. Three articles were excluded because the intervention was not a DHI aimed at secondary stroke prevention [20, 21, 22], 7 articles were excluded because they were reviews after thorough screening of the reference list [15, 23, 24, 25, 26, 27, 28], 1 article because it was a study protocol [29], and another article because the stroke patients were not the target population [30]. Zero papers were withheld for inclusion in this review.…”

ECG Monitoring Systems: Review, Architecture, Processes, and Key Challenges

“…This issue was addressed in several papers in the literature. Yong et al [253] suggested prolonged ECG monitoring for secondary stroke prevention, which eventually eliminates the cost of stroke treatment consequences. Additionally, prolonged and active monitoring significantly improved the diagnosis of AF and was associated with significantly lower emergency department visits and hospitalization requirements [254].…”