Ultra‐early continuous cardiac monitoring improves atrial fibrillation detection and prognosis of patients with cryptogenic stroke

Cuadrado-Godía, Elisa; Benito, Begoña; Ois, Ángel; Vallès, Ermengol; Rodríguez-Campello, Ana; Giralt‐Steinhauer, Eva; Cabrera, Sandra; Alcalde, Óscar; Jiménez‐López, Jesús; Jiménez‐Conde, Jordi; Martí-Almor, Julio; Roquer, Jaume

doi:10.1111/ene.14061

Cited by 23 publications

(29 citation statements)

References 19 publications

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“…Our results are in accordance with a recent meta‐analysis of RCTs and observational studies suggesting that prolonged cardiac monitoring is associated with more than 2‐fold higher chance of incident PAF detection and anticoagulation initiation, and a 65% relative risk reduction in stroke recurrence for patients with cryptogenic stroke or TIA 17 . Our observations parallel the results of another single‐center observational study from Spain reporting 70% reduction in risk of recurrent stroke in the ICM compared to the noninvasive cohort 18 …”

Section: Discussionsupporting

confidence: 91%

“…17 Our observations parallel the results of another single-center observational study from Spain reporting 70% reduction in risk of recurrent stroke in the ICM compared to the noninvasive cohort. 18 We also reported a median elapsed time of 4 months between ICM insertion and PAF. This finding further highlights the importance of implantable cardiac monitoring to uncover PAF in cryptogenic stroke, because the duration of prolonged Holter monitoring scarcely exceeds 1 month.…”

Section: Discussionmentioning

confidence: 89%

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Implantable Cardiac Monitoring in the Secondary Prevention of Cryptogenic Stroke

Triantafyllou

Katsanos

Dilaveris

et al. 2020

Annals of Neurology

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In this study, we sought to evaluate the impact of implantable cardiac monitoring (ICM) in the prevention of stroke recurrence after a cryptogenic ischemic stroke or transient ischemic attack (TIA). Methods: We evaluated consecutive patients with cryptogenic ischemic stroke or TIA admitted in a comprehensive stroke center during an 8-year period. We compared the baseline characteristics and outcomes between patients receiving conventional cardiac monitoring with repeated 24-hour Holter-monitoring during the first 5 years in the outpatient setting and those receiving continuous cardiac monitoring with ICM during the last 3 years. Associations on the outcomes of interest were further assessed in multivariable regression models adjusting for potential confounders. Results: We identified a total of 373 patients receiving conventional cardiac monitoring and 123 patients receiving ICM. Paroxysmal atrial fibrillation (PAF) detection was higher in the ICM cohort compared to the conventional cardiac monitoring cohort (21.1% vs 7.5%, p < 0.001). ICM was independently associated with an increased likelihood of PAF detection during follow-up (hazard ratio [HR] = 1.94, 95% confidence interval [CI] = 1.16-3.24) in multivariable analyses. Patients receiving ICM were also found to have significantly higher rates of anticoagulation initiation (18.7% vs 6.4%, p < 0.001) and lower risk of stroke recurrence (4.1% vs 11.8%, p = 0.013). ICM was independently associated with a lower risk of stroke recurrence during follow-up (HR = 0.32, 95% CI = 0.11-0.90) in multivariable analyses. Interpretation: ICM appears to be independently associated with a higher likelihood of PAF detection and anticoagulation initiation after a cryptogenic ischemic stroke or TIA. ICM was also independently related to lower risk of stroke recurrence in our cryptogenic stroke / TIA cohort.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 89%

Implantable Cardiac Monitoring in the Secondary Prevention of Cryptogenic Stroke

Triantafyllou

Katsanos

Dilaveris

et al. 2020

Annals of Neurology

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“…In the SURPRISE study [35], the implantation of the insertable cardiac monitor was also long after the CrS (median of 69 days) and the study population was younger than ours. Moreover, a recent study has shown that the diagnosis of AF by using an insertable cardiac monitor compared to conventional strategy increased AF detection after CrS [36].…”

Section: Discussionmentioning

confidence: 99%

“…Future studies in a greater population should confirm our findings; in particular, the values of myocardial deformation, as a consequence of their variability. AF guidelines [38] define clinical AF as lasting at least 30 s; although the AF burden related outcomes are not clear, we consider the definition of ≥1 min's duration, given that this cut-off value showed prognostic implications in a previous study after CrS [36].…”

Section: Discussionmentioning

confidence: 99%

Left Atrium Assessment by Speckle Tracking Echocardiography in Cryptogenic Stroke: Seeking Silent Atrial Fibrillation

Blé

Benito

Cuadrado-Godia

et al. 2021

JCM

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Silent atrial fibrillation (AF) may be the cause of some cryptogenic strokes (CrS). The aim of the study was to analyse atrial size and function by speckle tracking echocardiography in CrS patients to detect atrial disease. Patients admitted to the hospital due to CrS were included prospectively. Echocardiogram analysis included left atrial ejection fraction (LAEF) and atrial strain. Insertable cardiac monitor was implanted, and AF was defined as an episode of ≥1 min in the first year after stroke. Left atrial enlargement was defined as indexed volume > 34 mL/m2. Seventy-five consecutive patients were included, aged 76 ± 9 years (arterial hypertension 75%). AF was diagnosed in 49% of cases. The AF group had higher atrial volume and worse atrial function: peak atrial longitudinal strain (PALs) 19.6 ± 5.7% vs. 29.5 ± 7.2%, peak atrial contraction strain (PACs) 8.9 ± 3.9% vs. 16.5 ± 6%, LAEF 46.8 ± 11.5% vs. 60.6 ± 5.2%; p < 0.001. AF was diagnosed in 20 of 53 patients with non-enlarged atrium, and in 18 of them, atrial dysfunction was present. The multivariate logistic regression analysis demonstrated an independent association between detection of AF and atrial volume, LAEF, and strain. Cut-off values were obtained: LAEF < 55%, PALs < 21.4%, and PACs < 12.9%. In conclusion, speckle tracking echocardiography in CrS patients improves silent atrial disease diagnosis, with or without atrial enlargement.

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“…The relative simplicity of this predictive method makes it suitable for population screening of at-risk groups or those who cannot co-operate easily with clinical tests. The method may also be applied to analyze previously-collected data, e.g., to investigate links between subclinical AF and cryptogenic stroke (Healey et al, 2012) or development of dementia, when early screening would be especially useful (Cuadrado-Godia et al, 2020).…”

Section: Controlsmentioning

confidence: 99%

Prediction of Paroxysmal Atrial Fibrillation From Complexity Analysis of the Sinus Rhythm ECG: A Retrospective Case/Control Pilot Study

et al. 2021

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Paroxysmal atrial fibrillation (PAF) is the most common cardiac arrhythmia, conveying a stroke risk comparable to persistent AF. It poses a significant diagnostic challenge given its intermittency and potential brevity, and absence of symptoms in most patients. This pilot study introduces a novel biomarker for early PAF detection, based upon analysis of sinus rhythm ECG waveform complexity. Sinus rhythm ECG recordings were made from 52 patients with (n = 28) or without (n = 24) a subsequent diagnosis of PAF. Subjects used a handheld ECG monitor to record 28-second periods, twice-daily for at least 3 weeks. Two independent ECG complexity indices were calculated using a Lempel-Ziv algorithm: R-wave interval variability (beat detection, BD) and complexity of the entire ECG waveform (threshold crossing, TC). TC, but not BD, complexity scores were significantly greater in PAF patients, but TC complexity alone did not identify satisfactorily individual PAF cases. However, a composite complexity score (h-score) based on within-patient BD and TC variability scores was devised. The h-score allowed correct identification of PAF patients with 85% sensitivity and 83% specificity. This powerful but simple approach to identify PAF sufferers from analysis of brief periods of sinus-rhythm ECGs using hand-held monitors should enable easy and low-cost screening for PAF with the potential to reduce stroke occurrence.

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Ultra‐early continuous cardiac monitoring improves atrial fibrillation detection and prognosis of patients with cryptogenic stroke

Abstract: Biotronik, Inc gently provided 35 of the implantable cardiac monitors (Biomonitor®) required for this study. No other conflicts of interest regarding the present work.

Cited by 23 publications

References 19 publications

Implantable Cardiac Monitoring in the Secondary Prevention of Cryptogenic Stroke

Implantable Cardiac Monitoring in the Secondary Prevention of Cryptogenic Stroke

Left Atrium Assessment by Speckle Tracking Echocardiography in Cryptogenic Stroke: Seeking Silent Atrial Fibrillation

Prediction of Paroxysmal Atrial Fibrillation From Complexity Analysis of the Sinus Rhythm ECG: A Retrospective Case/Control Pilot Study

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