Prolonged Cardiac Monitoring and Stroke Recurrence: A Meta-analysis
Georgios Tsivgoulis1, Sokratis Triantafyllou1, Lina Palaiodimou1
1From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY.
Insights
Prolonged cardiac rhythm monitoring after ischemic stroke significantly increases atrial fibrillation detection and anticoagulant use. However, current randomized trials do not confirm a reduced risk of recurrent stroke with this approach.
Area of Science:
- Cardiology
- Neurology
- Medical Technology
Background:
- Ischemic stroke (IS) patients often have undetected atrial fibrillation (AF).
- Conventional monitoring has limitations in detecting AF post-stroke.
- Prolonged cardiac rhythm monitoring (PCM) may improve AF detection.
Purpose of the Study:
- To evaluate the association between PCM and stroke preventive strategies.
- To assess the impact of PCM on stroke recurrence.
- To compare AF detection rates and anticoagulation initiation between PCM and conventional monitoring.
Main Methods:
- Systematic search of MEDLINE and SCOPUS databases.
- Inclusion of 8 studies (5 RCTs, 3 observational) with 2,994 patients.
- Pairwise meta-analyses using a random effects model and indirect comparisons.
Main Results:
- PCM significantly increased AF detection and anticoagulant initiation in both RCTs and observational studies.
- Observational studies showed PCM was associated with lower recurrent stroke risk (RR 0.29).
- RCTs did not demonstrate a significant reduction in recurrent stroke risk with PCM (RR 0.72).
- Implantable loop recorders showed higher AF detection and anticoagulation initiation likelihood compared to Holter and external loop monitors.
Conclusions:
- PCM enhances AF detection and facilitates anticoagulant initiation in IS/TIA patients.
- Robust RCT evidence for PCM reducing stroke recurrence is currently lacking.
- Further research is needed to clarify the definitive benefit of PCM on stroke recurrence.
Background And Objectives:
Prolonged poststroke cardiac rhythm monitoring (PCM) reveals a substantial proportion of patients with ischemic stroke (IS) with atrial fibrillation (AF) not detected by conventional rhythm monitoring strategies. We evaluated the association between PCM and the institution of stroke preventive strategies and stroke recurrence.
Methods:
We searched MEDLINE and SCOPUS databases to identify studies reporting stroke recurrence rates in patients with history of recent IS or TIA receiving PCM compared with patients receiving conventional cardiac rhythm monitoring. Pairwise meta-analyses were performed under the random effects model. To explore for differences between the monitoring strategies, we combined direct and indirect evidence for any given pair of monitoring devices assessed within a randomized controlled trial (RCT).
Results:
We included 8 studies (5 RCTs, 3 observational; 2,994 patients). Patients receiving PCM after their index event had a higher rate of AF detection and anticoagulant initiation in RCTs (risk ratio [RR] 3.91, 95% CI 2.54-6.03; RR 2.16, 95% CI 1.66-2.80, respectively) and observational studies (RR 2.06, 95% CI 1.57-2.70; RR 2.01, 95% CI 1.43-2.83, respectively). PCM was associated with a lower risk of recurrent stroke during follow-up in observational studies (RR 0.29, 95% CI 0.15-0.59), but not in RCTs (RR 0.72, 95% CI 0.49-1.07). In indirect analyses of RCTs, the likelihood of AF detection and anticoagulation initiation was higher for implantable loop recorders compared with Holter monitors and external loop recorders.
Discussion:
PCM after an IS or TIA can lead to higher rates of AF detection and anticoagulant initiation. There is no solid RCT evidence supporting that PCM may be associated with lower stroke recurrence risk.
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