Detection of atrial fibrillation via adhesive single-lead ECG vs. Holter monitoring in embolic stroke of undetermined source: the AVANT-GARDE trial
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Published on: December 11, 2019
Jong-Ho Park1, Yerim Kim2, Seung-Jae Lee3
1Department of Neurology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
Insights
Extended patch electrocardiogram (ECG) monitoring significantly improves atrial fibrillation (AF) detection in embolic stroke of undetermined source (ESUS) patients compared to Holter. This enhanced detection aids in stroke prevention strategies.
Area of Science:
- Cardiology
- Neurology
- Medical Devices
Background:
- Detecting atrial fibrillation (AF) is critical for preventing recurrent strokes in embolic stroke of undetermined source (ESUS).
- Limited prospective data exists comparing single-lead patch electrocardiogram (ECG) with standard Holter monitoring for AF detection in ESUS.
- Subclinical AF detection is vital for optimizing secondary stroke prevention.
Purpose of the Study:
- To compare the efficacy of a 72-hour patch ECG versus 24-hour Holter monitoring in detecting AF in patients with acute ischemic stroke.
- To evaluate the diagnostic yield of extended monitoring in both ESUS and non-ESUS cohorts.
- To assess the association between AF detection and left atrial size.
Main Methods:
- Prospective, multicenter AVANT-GARDE trial comparing 72-hour patch ECG with 24-hour Holter monitoring.
- Primary cohort: 90 ESUS patients; Ancillary cohort: 23 non-ESUS patients with left atrial enlargement.
- Simultaneous monitoring at baseline and 72-hour patch monitoring at 6 months for the ESUS cohort.
Main Results:
- AF was detected in 13.3% of the total cohort at baseline, associated with larger left atrial size (p=0.037).
- The 72-hour patch ECG showed significantly higher AF detection rates than 24-hour Holter in both ESUS (16.7% vs. 5.6%, p=0.002) and overall cohorts (14.2% vs. 4.4%, p=0.001).
- Cumulative AF detection increased to 18.9% (ESUS) and 15.9% (overall) at 6 months, but prolonged AF episodes (≥30 seconds) did not differ significantly.
Conclusions:
- Extended 72-hour patch ECG monitoring significantly enhances AF detection rates compared to 24-hour Holter in ESUS patients.
- Short-duration AF (<30 seconds) detected by patch ECG may indicate subclinical atrial cardiopathy, warranting long-term surveillance.
- Larger studies are needed to validate these findings and guide clinical practice for stroke prevention.
Background:
Detecting atrial fibrillation (AF) is crucial for preventing stroke recurrence in embolic stroke of undetermined source (ESUS). However, prospective data directly comparing a single-lead patch electrocardiogram (ECG) with standard Holter monitoring remain limited.
Methods:
The AVANT-GARDE trial was a prospective, multicenter study comparing a 72-h patch ECG with 24-h Holter monitoring. Among 113 acute ischemic stroke patients, 90 with ESUS formed the primary cohort, and 23 non-ESUS patients with left atrial enlargement were included as an ancillary cohort. Patients underwent simultaneous monitoring at baseline, with an additional 72-h patch monitoring at 6 months for the ESUS cohort.
Results:
At baseline, AF was identified in 13.3% of the cohort, associated with larger LA size (41.8 ± 5.1 mm vs. 38.3 ± 5.9 mm; p = 0.037). The 72-h patch ECG monitor demonstrated a higher AF detection rate at baseline than 24-h Holter in both the ESUS cohort (16.7% vs. 5.6%, p = 0.002) and the overall cohort (14.2% vs. 4.4%, p = 0.001). At 6 months, two additional AF episodes (any duration) were identified, increasing cumulative detection rates to 18.9% in the ESUS cohort and 15.9% in the overall cohort (p < 0.001 vs. baseline Holter). However, the number of prolonged AF episodes lasting ≥30 seconds did not differ significantly between the two modalities.
Conclusions:
Extended patch ECG monitoring enhances the AF detection rate over conventional Holter in patients with ESUS. For short-duration AF (<30 seconds), it should be interpreted as an exploratory marker of subclinical atrial cardiopathy requiring long-term clinical surveillance. Large-scale studies are warranted to confirm these clinical findings.
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