Detection of Atrial Fibrillation after Ischemic Stroke with an Insertable Cardiac Monitor: A Systematic Review and...

We compared the use of insertable cardiac monitor (ICM) versus non-ICM methods of cardiac monitoring in ischemic stroke patients on the detection of atrial fibrillation (AF) and other clinical outcomes. Current guidelines recommend the routine use of 12-lead electrocardiography or Holter monitoring for AF detection after ischemic stroke. Recent randomized controlled trials have investigated the impact of ICM versus non-ICM methods of cardiac monitoring for AF detection in this population. However, precise recommendations for monitoring poststroke AF are lacking, including the optimal timing, duration, and method of electrocardiography monitoring.

A systematic search was conducted on Embase and PubMed from database inception until October 27, 2022, to include randomized controlled trials that compared ICM with non-ICM methods of cardiac monitoring for poststroke AF detection. This yielded 3 randomized controlled trials with a combined cohort of 1,233 patients with a recent ischemic stroke. Individual patient data (IPD) were then reconstructed from Kaplan-Meier curves and analyzed using the shared-frailty Cox model. An aggregate data meta-analysis was conducted for 1,233 patients across all 3 studies for outcomes that could not be reconstructed using IPD.

One-stage meta-analysis demonstrated an increase in the hazard ratio (6.00 95% CI: 3.40-10.58; 195 p < 0.001) of AF detection in patients undergoing monitoring via ICM compared to standard care. The cumulative incidence curves of AF events in patients undergoing ICM and non-ICM separated significantly at 24 days. Aggregate data meta-analysis revealed a significant increase in initiation of anticoagulation (RR: 2.76, 95% CI: 1.89-4.02, p < 0.00001) in the ICM group. However, no significant differences in the incidence of recurrent ischemic stroke, transient ischemic attack, or death were found.

In this meta-analysis, we found that the use of ICM increased the detection rate of poststroke AF and the rate of anticoagulation initiation in ischemic stroke patients. However, this did not translate into a reduced incidence of recurrent ischemic stroke.