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Cryptogenic stroke and underlying atrial fibrillation

Tommaso Sanna1, Hans-Christoph Diener, Rod S Passman

  • 1From the Catholic University of the Sacred Heart, Institute of Cardiology (T.S.), and Institute of Neurology, Campus Bio-Medico University (V.D.L.) - both in Rome; the Department of Neurology and Stroke Center, University Hospital Essen, Essen (H.-C.D.), and Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg (J.B.) - both in Germany; Bluhm Cardiovascular Institute (R.S.P.) and Davee Department of Neurology (R.A.B.), Northwestern University Feinberg School of Medicine, Chicago; Population Health Research Institute, McMaster University, Hamilton, ON, Canada (C.A.M.); University of Kansas Medical Center, Kansas City (M.M.R.); the KU Leuven Department of Neurosciences, the VIB-Vesalius Research Center, and the Department of Neurology, University Hospitals Leuven - all in Leuven, Belgium (V.T.); Medtronic, Mounds View, MN (T.R., K.L.); and Medtronic, Maastricht, the Netherlands (F.B.).

The New England Journal of Medicine
|June 26, 2014
PubMed

Insights

Long-term monitoring with an insertable cardiac monitor (ICM) significantly improved the detection of atrial fibrillation in cryptogenic stroke patients compared to standard follow-up. This finding has important implications for stroke management and prevention strategies.

Area of Science:

  • Cardiology
  • Neurology
  • Medical Devices

Background:

  • Current guidelines suggest 24-hour ECG monitoring post-ischemic stroke to detect atrial fibrillation (AF).
  • The optimal duration and method for AF detection remain unclear, especially in cryptogenic stroke cases where the cause is often undetermined.
  • Identifying AF in cryptogenic stroke patients is crucial for guiding therapeutic decisions and preventing recurrent events.

Purpose of the Study:

  • To evaluate the efficacy of long-term monitoring using an insertable cardiac monitor (ICM) versus conventional follow-up for detecting atrial fibrillation in patients with cryptogenic stroke.
  • To compare the time to the first detection of atrial fibrillation within 6 and 12 months between the ICM and control groups.

Main Methods:

  • A randomized, controlled trial involving 441 patients aged 40 years or older with cryptogenic stroke and no initial evidence of AF.
  • Patients were randomized to either ICM monitoring or conventional follow-up within 90 days of the index event.
  • The primary endpoint was the detection of atrial fibrillation (lasting >30 seconds) within 6 months, with a secondary endpoint at 12 months. Data analysis followed the intention-to-treat principle.

Main Results:

  • At 6 months, atrial fibrillation was detected in 8.9% of the ICM group versus 1.4% of the control group (HR 6.4; P<0.001).
  • By 12 months, atrial fibrillation detection rates were 12.4% in the ICM group compared to 2.0% in the control group (HR 7.3; P<0.001).
  • The ICM group demonstrated a significantly higher rate of AF detection throughout the study period.

Conclusions:

  • Insertable cardiac monitor (ICM) use is superior to conventional follow-up for detecting atrial fibrillation in patients with cryptogenic stroke.
  • Long-term ICM monitoring offers a more effective strategy for identifying AF, enabling timely therapeutic interventions.
  • The CRYSTAL AF study (NCT00924638) provides robust evidence supporting ICMs in cryptogenic stroke management.
Abstract

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