Time trends and patient selection in the use of continuous electrocardiography for detecting atrial fibrillation after stroke: a nationwide cohort study

Abstract

Background and purpose: Clinical use of continuous electrocardiography (cECG) for detecting atrial fibrillation (AF) after stroke is unclear. In a Danish nationwide cohort, we described post-stroke time trends in outpatient cECG usage and AF incidence and characterized factors associated with cECG use. Methods: Patients without AF discharged after their first ischaemic stroke between 2010 and 2016 were identified from Danish nationwide registries. cECG included Holter or event recording within 120 days from discharge. Cumulative incidence analysis and multivariable adjusted logistic regression were used to assess time trends and factors associated with cECG usage and AF. Results: The study population comprised 39 641 patients. Cumulative use of cECG increased threefold from 3.3% [95% confidence intervals (CI), 2.8-3.8] in 2010 to 10.5% (95% CI, 9.7-11.3) in 2016. Correspondingly, cumulative incidence of post-stroke AF increased from 1.9% (95% CI, 1.5-2.3) to 2.8% (95% CI, 2.4-3.2). Of all cECG-evaluated patients, 6.3% received an AF diagnosis versus 2.2% of the unevaluated. Receiving cECG was associated with increased odds of AF (odds ratio, 3.4; 95% CI, 2.8-4.0). Lower age, milder strokes and less comorbidity were associated with increased odds of receiving cECG. In contrast, risk factors for AF were increasing age and more comorbidity. Conclusions: Post-stroke outpatient cECG use and AF incidence have increased over time, but screening rates were low. cECG use was associated with tripled odds of detecting AF. There was a disparity between factors associated with cECG use and risk factors of AF. This raise questions as to the appropriateness of the current clinical approach to post-stoke AF detection.

Searching for atrial fibrillation post stroke: is it time for digital devices?

“…This is not a recent problem: the Ontario Stroke Registry for patients managed between 2003 and 2013 found a 30% rate of 24-h Holter ECGs performed and less than 1% for longer Holter duration ( 7 ) whereas this was not the case for cardiac ultrasound. AF detection is far from optimal today too, with a use of ECG monitoring in around 10% of post IS patients in a Danish nationwide cohort, not correlated with risk factors of AF raising the appropriateness of screening ( 8 ). The use of ILR in daily practice is limited to a subset of patients, estimated at 15% in a US cohort of nearly 13,000 patients with CS ( 9 ).…”