Detection of subclinical atrial fibrillation after cryptogenic stroke using implantable cardiac monitors
Andrea Ungar1, Francesca Pescini2, Martina Rafanelli1
1Division of Geriatric and Intensive Care Medicine, Syncope Unit, University of Florence, Firenze, Italy.
Insights
Implantable cardiac monitors detected subclinical atrial fibrillation (SCAF) in over a quarter of cryptogenic stroke patients in a real-world study. This confirms ICM
Area of Science:
- Cardiology
- Neurology
- Medical Devices
Background:
- Subclinical atrial fibrillation (SCAF) is detected in up to 30% of cryptogenic stroke (CS) patients via implantable cardiac monitors (ICMs) in trials.
- Real-world data on SCAF occurrence and predictors in CS patients are limited.
Purpose of the Study:
- To investigate SCAF occurrence, treatments, clinical outcomes, and predictors in a real-world CS population using ICMs.
Main Methods:
- A multicenter study followed 334 CS patients implanted with ICMs from September 2016 to November 2019.
- Remote and outpatient follow-up was conducted, with device-detected AF events confirmed by cardiologists to diagnose SCAF.
Main Results:
- SCAF was diagnosed in 92 (27.5%) patients during a median follow-up of 23.6 months.
- The first SCAF episode was asymptomatic in 88.1% of cases.
- Independent predictors of SCAF included female gender, age >69 years, PR interval >160 ms, and cortical-subcortical infarct type.
Conclusions:
- ICM implantation is relevant for detecting SCAF in CS patients, especially after Holter monitoring failure.
- Further research is needed to confirm if oral anticoagulation after SCAF detection reduces recurrent stroke risk.
Background:
Implantable cardiac monitor (ICM) revealed subclinical atrial fibrillation (SCAF) in up to 30% of cryptogenic stroke (CS) patients in randomized trials. However, real world data are limited.
Objectives:
We investigated SCAF occurrence, treatments, clinical outcomes and predictors of SCAF in a multicenter real-world population subjected to ICM after CS.
Methods:
From September 2016 to November 2019, 20 Italian centers collected data of consecutive patients receiving ICM after CS and followed with remote and outpatient follow-up according to clinical practice. All device-detected AF events were confirmed by the cardiologist to diagnose SCAF.
Results:
ICM was implanted in 334 CS patients (mean age±SD 67.4±11.5 years, 129 (38.6%) females, 242 (76.1%) with CHA2DS2-VASC score≥4). During a follow-up of 23.6 (IQR 14.6-31.5) months, SCAF was diagnosed in 92 (27.5%) patients. First episode was asymptomatic in 81 (88.1%). SCAF daily burden ≥5 minutes was 22.0%, 24.1% and 31.5% at 6, 12, and 24 months after ICM implantation. Median time to first day with AF was 60 (IQR 18-140) days. Female gender, age>69 years, PR interval>160 ms and cortical-subcortical infarct type at enrolment were independently associated with an increased risk of SCAF.
Conclusions:
In a real-world population, ICM detected SCAF in more than a quarter of CS patients. This experience confirms the relevance of implanting CS patients, for maximizing the possibilities to detect AF, following failure of Holter monitoring, according to guidelines. However, there is need to demonstrate that shift to oral anticoagulation following SCAF detection is associated with reduced risk of recurrent stroke.
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