TIAS (Timing, Individualised, Amalgamated, Stepwise) Algorithm for Efficacious and Cost-Effective Cardiac Monitoring...

Atrial fibrillation (AF) is a significant contributor to cardioembolic stroke and often remains undiagnosed in cryptogenic or embolic strokes of undetermined source (ESUS). Extended cardiac monitoring has become a crucial strategy for enhancing post-stroke AF detection. Landmark trials such as EMBRACE, ASSERT, and CRYSTAL-AF have demonstrated higher AF detection rates with longer or implantable devices compared to standard short-term electrocardiograms (ECGs). This narrative review examines selected randomised controlled trials (RCTs), extensive prospective studies, meta-analyses, and guideline statements, while excluding case reports, small single-centre studies, and reports without AF detection endpoints on extended cardiac monitoring. It provides a detailed comparison of different monitoring strategies alongside their relative cost-effectiveness. It primarily assesses cost per quality-adjusted life year (QALY), direct healthcare expenditure, and, where available, indirect costs such as readmissions, complications, accessibility, and benefits. The review also introduces the innovative "TIAS" strategy for cardiac monitoring following stroke, which stands for Timing, Individualised, Amalgamated, and Stepwise approach. It aims to assist clinicians in developing an evidence-based, cost-effective plan for cardiac monitoring. By employing customised monitoring strategies that account for each patient's risk factors, stroke subtype, and healthcare setting, the TIAS approach aims to improve AF diagnosis and reduce the likelihood of stroke recurrence, while acknowledging limitations such as heterogeneity across trials, uncertainty about AF burden thresholds, and challenges in real-world implementation across variable healthcare systems.