Rhythm monitoring strategies for atrial fibrillation detection in patients with cryptogenic stroke: A systematic review and meta-analysis

Abstract

Objective To summarize data on atrial fibrillation (AF) detection rates and predictors across different rhythm monitoring strategies in patients with cryptogenic stroke (CS) or embolic stroke of undetermined source (ESUS). Methods MEDLINE, Embase, and Web of Science were searched to identify all published studies providing relevant data through July 6, 2020. Random-effects meta-analysis method was used to pool estimates. Results We included 47 studies reporting on a pooled population of 8,215 patients with CS or ESUS. Using implantable cardiac monitor (ICM), the pooled rate of AF was 12.2% (95% CI 9.4–15.0) at 3 months, 16.0% (95% CI 13.2–18.8) at 6 months, 18.7% (95% CI 15.7–21.7) at 12 months, 22.8% (95% CI 19.1–26.5) at 24 months, and 28.5% (95% CI 17.6–39.3) at 36 months. AF rates were significantly higher in patients with ESUS vs CS (22.0% vs 14.2%; p < 0.001) at 6 months, and in studies using Reveal LINQ vs Reveal XT ICM (19.1% vs 13.0%; p = 0.001) at 12 months. Using mobile cardiac outpatient telemetry (MCOT), the pooled rate of AF was 13.7% (95% CI 10.2–17.2) at 1 month. Predictors of AF detection with ICM included older age, CHA 2 DS 2 -VASc score, left atrial enlargement, P wave maximal duration and prolonged PR interval. Conclusion The yield of ICM increases with the duration of monitoring. More than a quarter of patients with CS or ESUS will be diagnosed with AF during follow-up. About one in seven patients had AF detected within a month of MCOT, suggesting that a non-invasive rhythm monitoring strategy should be considered before invasive monitoring.

Non-stenotic Carotid Plaques in Embolic Stroke of Unknown Source

“…The ongoing Clopidogrel with Aspirin in High-risk patients with Acute Non-disabling Cerebrovascular Events II (CHANCE-2, NCT04078737) trial is evaluating the superiority of the Ticagrelor-Aspirin combination over Clopidogrel-Aspirin therapy in CYP2C19 loss of function carriers with minor stroke or transient ischemic attack (TIA)(113).AnticoagulationTheNew Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial vs. ASA [Acetylsalicylic Acid] to Prevent Embolism in Embolic Stroke of Undetermined Source (NAVIGATE-ESUS) and the Randomized Double-Blind Evaluation in Secondary Stroke Prevention Comparing The Efficacy Of Oral Thrombin Inhibitor Dabigatran Etexilate for Secondary Stroke Prevention in Patients With Embolic Stroke of Undetermined Source (RE-SPECT-ESUS) trials have shown that universal full-dose oral anticoagulation is not an effective strategy to reduce the risk of stroke recurrence in patients with ESUS(5,6). These results are likely explained by the heterogeneity of stroke mechanisms in patients with ESUS as discussed earlier, with atrial fibrillation being diagnosed in only 24.8% of cases at 24 months using insertable cardiac monitors(115). Moreover, there is no evidence that patients with ESUS and ipsilateral non-stenotic carotid plaques should be treated differently than those without plaques.…”

Clinical Implications of Atrial Fibrillation Detection Using Wearable Devices in Patients With Cryptogenic Stroke (CANDLE-AF) Trial: Design and Rationale

“…Based on this, we thought that it would be more cost-effective to monitor only once every 3 months than to monitor 2 or 3 months respectively. On the other hand, it is unclear whether AF found in monitoring after 1 year has a causative role for index stroke ( 15 ). This is because risk factors for stroke or factors that stroke patients usually have, such as metabolic disease and old age, may be the cause of AF found by longer monitoring ( 20 ).…”

“…According to the 2020 guideline of the European Society of Cardiology ( 3 ), single-lead ECG recording using a wearable device can be used for confirming a diagnosis of AF (Class of recommendation: Ia). A recent systematic review and meta-analysis suggested a noninvasive rhythm-monitoring strategy prior to invasive monitoring ( 15 ). Against this background, we designed a trial that compares a single-lead patch to an event-type recorder and standard care, respectively.…”

Long-Term Cardiac Monitoring After Embolic Stroke of Undetermined Source: Search Longer, Look Harder

“…21 In the same study, among patients with ICM long-term continuous monitoring was found to be superior in detecting atrial fibrillation compared to several intermittent monitoring strategies. 22 A recent meta-analysis including 47 studies and 8,215 patients with cryptogenic or ESUS stroke using ICMs or noninvasive cardiac monitoring showed that the rate of atrial fibrillation detection by ICMs increased by the duration of follow-up (range from 2.0% [95% CI: 0.0-5.6, I 2 : 52%] at 1 week to 28.5% [95% CI:17.6-39.3, I 2 92%] at 36 months), 23 were positively corelated to atrial fibrillation detection. 23 The recently published Post-Embolic Rhythm Detection With Implantable Versus External Monitoring (PER DIEM) randomized trial including 300 patients with cryptogenic stroke, confirmed that the detection of atrial fibrillation lasting >2 minutes was significantly higher in longterm monitoring with ILR compared with external loop recorders.…”

“…22 A recent meta-analysis including 47 studies and 8,215 patients with cryptogenic or ESUS stroke using ICMs or noninvasive cardiac monitoring showed that the rate of atrial fibrillation detection by ICMs increased by the duration of follow-up (range from 2.0% [95% CI: 0.0-5.6, I 2 : 52%] at 1 week to 28.5% [95% CI:17.6-39.3, I 2 92%] at 36 months), 23 were positively corelated to atrial fibrillation detection. 23 The recently published Post-Embolic Rhythm Detection With Implantable Versus External Monitoring (PER DIEM) randomized trial including 300 patients with cryptogenic stroke, confirmed that the detection of atrial fibrillation lasting >2 minutes was significantly higher in longterm monitoring with ILR compared with external loop recorders. 24 In this study, atrial fibrillation detection rate was 15.3% among patients with cryptogenic stroke followed with ILRs for 12 months compared with 4.7% in the group of external monitoring for 30 days (risk ratio [RR]: 3.29, 95% CI: 1.45-7.42).…”