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Atrial premature beats predict atrial fibrillation in cryptogenic stroke: results from the EMBRACE trial
David J Gladstone1, Paul Dorian2, Melanie Spring2
1From the Division of Neurology (D.J.G.), Department of Medicine (D.J.G., P.D., M.S., M.M.), and Dalla Lana School of Public Health (K.E.T.), University of Toronto, Toronto, Ontario, Canada; University of Toronto Stroke Program, Toronto, Ontario, Canada (D.J.G.); Division of Neurology, Department of Medicine, and the Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada (D.J.G.); Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada (D.J.G.); Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (M.M., V.P., K.E.T.); and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.). david.gladstone@sunnybrook.ca.
Insights
Frequent atrial premature beats (APBs) on a 24-hour Holter ECG predict subclinical atrial fibrillation (AF) in cryptogenic stroke patients. Higher APB counts indicate a greater likelihood of AF, guiding prolonged monitoring decisions.
Area of Science:
- Cardiology
- Neurology
- Clinical Electrophysiology
Background:
- Cryptogenic stroke and transient ischemic attacks (TIAs) are often linked to undetected atrial fibrillation (AF).
- Identifying patients at high risk for subclinical AF is crucial for stroke prevention.
Purpose of the Study:
- To identify predictors of subclinical atrial fibrillation (AF) in patients with cryptogenic stroke or TIA.
- To determine which baseline variables are associated with AF detection.
Main Methods:
- Prospective study of patients aged ≥55 years with cryptogenic stroke/TIA in sinus rhythm.
- Baseline 24-hour Holter ECG followed by random assignment to 30-day ECG monitoring if AF was not detected.
- Multivariable logistic regression analyzed predictors like atrial premature beats (APBs), atrial tachycardia, age, and left atrial enlargement.
Main Results:
- A higher count of APBs on baseline Holter ECG strongly predicted subsequent AF detection.
- APB count was the sole significant predictor of AF detection at 30 days, 90 days, and 2 years.
- The probability of AF detection increased in a dose-dependent manner with higher APB counts.
Conclusions:
- The number of APBs on a 24-hour Holter ECG is a significant, dose-dependent predictor of subclinical AF in older patients with cryptogenic stroke/TIA.
- Patients with frequent APBs are ideal candidates for prolonged ECG monitoring to detect AF.
Background And Purpose:
Many ischemic strokes or transient ischemic attacks are labeled cryptogenic but may have undetected atrial fibrillation (AF). We sought to identify those most likely to have subclinical AF.
Methods:
We prospectively studied patients with cryptogenic stroke or transient ischemic attack aged ≥55 years in sinus rhythm, without known AF, enrolled in the intervention arm of the 30 Day Event Monitoring Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event (EMBRACE) trial. Participants underwent baseline 24-hour Holter ECG poststroke; if AF was not detected, they were randomly assigned to 30-day ECG monitoring with an AF auto-detect external loop recorder. Multivariable logistic regression assessed the association between baseline variables (Holter-detected atrial premature beats [APBs], runs of atrial tachycardia, age, and left atrial enlargement) and subsequent AF detection.
Results:
Among 237 participants, the median baseline Holter APB count/24 h was 629 (interquartile range, 142-1973) among those who subsequently had AF detected versus 45 (interquartile range, 14-250) in those without AF (P<0.001). APB count was the only significant predictor of AF detection by 30-day ECG (P<0.0001), and at 90 days (P=0.0017) and 2 years (P=0.0027). Compared with the 16% overall 90-day AF detection rate, the probability of AF increased from <9% among patients with <100 APBs/24 h to 9% to 24% in those with 100 to 499 APBs/24 h, 25% to 37% with 500 to 999 APBs/24 h, 37% to 40% with 1000 to 1499 APBs/24 h, and 40% beyond 1500 APBs/24 h.
Conclusions:
Among older cryptogenic stroke or transient ischemic attack patients, the number of APBs on a routine 24-hour Holter ECG was a strong dose-dependent independent predictor of prevalent subclinical AF. Those with frequent APBs have a high probability of AF and represent ideal candidates for prolonged ECG monitoring for AF detection.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00846924.
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