Download PDF
Thromb Haemost 2017; 117(10): 1962-1969
DOI: 10.1160/TH17-02-0072
Stroke, Systemic or Venous Thromboembolism
Schattauer GmbH

Detection of atrial fibrillation in patients with embolic stroke of undetermined source by prolonged monitoring with implantable loop recorders

Carsten Israel
1   Department of Cardiology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
,
Alkisti Kitsiou
2   Department of Neurology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
,
Malik Kalyani
1   Department of Cardiology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
,
Sameera Deelawar
1   Department of Cardiology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
,
Lucy Ekosso Ejangue
1   Department of Cardiology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
,
Andreas Rogalewski
2   Department of Neurology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
,
Christoph Hagemeister
2   Department of Neurology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
,
Jens Minnerup
3   Department of Neurology, University Hospital Münster, Germany
,
Wolf-Rüdiger Schäbitz
2   Department of Neurology, Evangelisches Klinikum Bethel, EvKB, Bielefeld, Bielefeld, Germany
› Author Affiliations
Further Information

Publication History

Received: 06 February 2017

Accepted after major revision: 24 January 2017

Publication Date:
28 November 2017 (online)

    Permissions and Reprints

Summary

Recently, the clinical entity embolic stroke of undetermined source (ESUS) has been defined for patients with ischemic strokes, where neither a cardioembolic nor a non-cardiac source can be detected. These patients may suffer from asymptomatic atrial fibrillation (AF), terminating spontaneously and thus eluding detection. Implantable loop recorders (ILR) with automatic AF detection algorithms can detect short-lasting, subclinical AF. The aim of this study was to prospectively assess and predict AF detection in patients with ESUS using ILR with daily remote interrogation. Patients with acute ESUS received an ILR, were seen every 6 months and additionally interrogated their ILR daily using remote monitoring. The incidence of AF detection was assessed and parameters which might predict AF detection (clinical and from magnetic resonance tomography) were analysed. ILR implantation was performed in 123 patients on average 20 days after stroke. During a mean follow-up of 12.7±5.5 months, AF was documented and manually confirmed in 29 of 123 patients (23.6%). First AF detection occurred on average after 3.6±3.4 months of monitoring. Patients with AF were on average older, had a higher CHA2DS2-VASc score and more often cerebral microangiopathy. In conclusion, AF can be documented in approximately 25% of patients with the diagnosis of ESUS after careful work-up within a year of monitoring by an ILR and daily remote interrogation. This had important therapeutic consequences (initiation of anticoagulation for secondary stroke prevention) in these patients.

Key words

Atrial fibrillation - embolic stroke of undetermined source - implantable - loop-recorder - remote monitoring - stroke
 

  • References

  • 1 Kolominsky-Rabas PL, Weber M, Gefeller O. et al. Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, re- currence, and long-term survival in ischemic stroke subtypes: a population-based study. Stroke 2001; 32: 2735-2740.
    CrossrefPubMedGoogle Scholar
  • 2 Marini C, De Santis F, Sacco S. et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke 2005; 36: 1115-1119.
    CrossrefPubMedGoogle Scholar
  • 3 Li L, Yiin GS, Geraghty OC. et al. Oxford Vascular Study. Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient ischaemic attack and ischaemic stroke: a population-based study. Lancet Neurol 2015; 14: 903-913.
    CrossrefPubMedGoogle Scholar
  • 4 Jauch EC, Saver JL, Adams Jr HP. et al. American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44: 870-947.
    CrossrefPubMedGoogle Scholar
  • 5 ESO executive Committee: ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischemic attack. Cerbrovasc Dis 2008; 25: 457-507.
    PubMedGoogle Scholar
  • 6 Ritter MA, Kochhäuser S, Duning T. et al. Occult Atrial Fibrillation in Cryptogenic Stroke Detection by 7-Day Electrocardiogram Versus Implantable Cardiac Monitors. Stroke 2013; 44: 1449-1452.
    CrossrefPubMedGoogle Scholar
  • 7 Grond G, Jauss M, Hamann G. et al. Improved Detection of Silent Atrial Fibrillation Using 72-Hour Holter ECG in Patients With Ischemic Stroke. Stroke 2013; 44: 3357-3364.
    CrossrefPubMedGoogle Scholar
  • 8 Cotter PE, Martin PJ, Ring L. et al. Incidence of atrial fibrillation detected by implant- able loop recorders in unexplained stroke. Neurology 2013; 80: 1546-1550.
    CrossrefPubMedGoogle Scholar
  • 9 Sanna T, Diener HC, Passman RS. et al. for the CRYSTAL AF Investigators. Cryptogenic Stroke and Underlying Atrial Fibrillation. N Engl J Med 2014; 370: 2478-2486.
    CrossrefPubMedGoogle Scholar
  • 10 Gladstone DJ. for the EMBRACE Investigators and Coordinators. Atrial Fibrillation in Patients with Cryptogenic Stroke. N Engl J Med 2014; 370: 2467-2477.
    CrossrefPubMedGoogle Scholar
  • 11 Hart RG, Diener HC, Coutts SB. et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13: 429-438.
    CrossrefPubMedGoogle Scholar
  • 12 Hindricks G, Pokushalov E, Urban L. et al. XPECT Trial Investigators. Performance of new leadless implantable cardiac monitor in detecting and quantifying atrial fibrillation: results of the XPECT trial. Circ Arrhythm Electrophysiol 2010; 03: 141-147.
    CrossrefPubMedGoogle Scholar
  • 13 Passman R, Rymer MM, Liu S, Ziegler PD. Incidence of Atrial Fibrillation among Patients with an Embolic Stroke of Undetermined Source (ESUS). ISC; 2017. Feb. 22–24 Houston USA.:
    Google Scholar
  • 14 Sposato LA, Cipriano LE, Saposnik G. et al. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 2015; 14: 377-387.
    CrossrefPubMedGoogle Scholar
  • 15 Eitel C, Husser D, Hindricks G. et al. Performance of an implantable automatic atrial fibrillation detection device: impact of software adjustments and relevance of manual episode analysis. Europace 2011; 13: 480-485.
    CrossrefPubMedGoogle Scholar
  • 16 Mittal S, Rogers J, Sarkar S. et al. Real-world performance of an enhanced atrial fibrillation detection algorithm in an insertable cardiac monitor. Heart Rhythm 2016; 13: 1624-1630.
    CrossrefPubMedGoogle Scholar
  • 17 Ntaios G, Papavasileiou V, Milionis H. et al. Embolic Strokes of Undetermined Source in the Athens Stroke Registry: An Outcome Analysis. Stroke 2015; 46: 176-181.
    CrossrefPubMedGoogle Scholar
  • 18 Ntaios G, Papavasileiou V, Lip GY. et al. Embolic Stroke of Undetermined Source and Detection of Atrial Fibrillation on Follow-Up: How Much Causality Is There?. J Stroke Cerebrovasc Dis 2016; 25: 2975-2980.
    CrossrefPubMedGoogle Scholar
  • 19 Hohnloser SH, Pajitnev D, Pogue J. et al. Incidence of stroke in paroxysmal versus sustained atrial fibrillation in patients taking oral anticoagulation or combined antiplatelet therapy: an ACTIVE W Substudy. J Am Coll Cardiol 2007; 50: 2156-2161.
    CrossrefPubMedGoogle Scholar
  • 20 Healey JS, Connolly SJ, Gold MR. et al. for the ASSERT investigators. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012; 366: 120-129.
    CrossrefPubMedGoogle Scholar
  • 21 Van Gelder IC, Healey JS, Crijns HJGM. et al. Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT. Eur Heart J 2017; 38: 1339-1344.
    CrossrefPubMedGoogle Scholar
  • 22 The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology. Guidelines for the management of atrial fibrillation. Eur Heart J 2010; 31: 2369-2429.
    CrossrefPubMedGoogle Scholar
  • 23 Calkins H, Kuck KH, Cappato R. et al. 2012 HOURS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and re- search trial design: a report of the Heart Rhythm Society (HOURS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Heart Rhythm 2012; 09: 632-696.
    CrossrefPubMedGoogle Scholar
  • 24 Healey JS. ASSERT-II: Subclinical atrial fibrillation (SCAF) in older asymptomatic patients. Presented at the American Heart Association Scientific Sessions, New Orleans, November 15th 2016
    PubMedGoogle Scholar
  • 25 Diener HC, Easton JD, Granger CB. et al. Respect-Esus Investigators. Design of Randomized, double-blind, Evaluation in secondary Stroke Prevention comparing the EfficaCy and safety of the oral Thrombin inhibitor dabigatran etexilate vs. acetylsalicylic acid in patients with Embolic Stroke of Undetermined Source (RE-SPECT ESUS). Int J Stroke 2015; 10: 1309-1312.
    CrossrefPubMedGoogle Scholar
  • 26 Hemmrich M, Peterson ED, Thomitzek K, Weitz JI. Spotlight on unmet needs in stroke prevention. The PIONEER AF-PCI, NAVIGATE ESUS and GALILEO trials. Thromb Haemost 2016; 116 (02) S33-S40.
    Article in Thieme ConnectPubMedGoogle Scholar