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A call for monitoring for AF in post-stroke patients

Routine noninvasive cardiac-event monitoring after acute stroke enhances detection of paroxysmal atrial fibrillation (AF) and early anticoagulation, according to a study1 published recently in Stroke.

The authors hypothesised that seven days of noninvasive cardiac-event monitoring early after stroke would accelerate detection of AF, and thus uptake of effective therapy. They assessed 101 patients presenting in sinus rhythm with no AF history, within seven days of ischaemic stroke symptom onset. Patients were randomised to standard practice investigations (SP) to detect AF, or SP plus additional monitoring (SP-AM). AM comprised seven days of noninvasive cardiac-event monitoring reported by an accredited cardiac electrocardiology laboratory. Primary outcome was detection of AF at 14 days.

101 patients were enrolled from two centers. Within 14 days of stroke, sustained paroxysms of AF were detected in 18% of patients undergoing SP-AM versus 2% undergoing SP (P<0.05). Paroxysms of any duration were detected in 44% of patients undergoing SP-AM versus 4% undergoing SP (P<0.001). These differences persisted at 90 days. Anticoagulant therapy was commenced within 14 days in 16% of SP-AM patients versus none randomized to SP (P<0.01). This difference persisted to 90 days (22% versus 6%; P<0.05).

Extended monitoring should be offered to all eligible patients soon after acute stroke, and guidelines on investigation for AF in stroke patients could be strengthened, say the authors.

Speaking to BJC Arrhythmia Watch, co-author Dr Peter Higgins (Gardiner Institute, Western Infirmary, University of Glasgow) said: “Following ischaemic stroke (IS) and transient ischaemic attack (TIA), the presence of atrial fibrillation (AF) identifies a subgroup of patients at particularly increased risk of a subsequent, potentially devastating stroke. Anticoagulant therapy provides a clear benefit over antiplatelet therapy but may only be instituted if AF is identified.”

“National and international guidelines make limited recommendations regarding AF detection strategies, reflecting a lack of randomised and controlled studies. In the UK, a recent survey of stroke physicians suggested investigation additional to the admission 12-lead ECG is performed in the minority of IS and TIA patients,” he added.

“Our study provides randomised evidence that routine application of seven days monitoring, with a non-invasive cardiac event device, is superior to current guideline based clinical practice for the detection of AF following stroke. We recommend that such monitoring be performed in all IS and TIA patients who would potentially be eligible for anticoagulant therapy,” Dr Higgins said.

“Regarding UK estimates of investigation, we cited O’Brien and Lees’ survey of UK stroke physicians in the manuscript. This survey of UK stroke physicians suggested existing guidelines are adhered to. However this amounts to inconsistent use of additional monitoring (to the minimum requirement of a 12-lead ECG on admission with IS or TIA), essentially at the discretion of the treating physician. The most frequent additional monitoring modality in the UK appeared to be the 24-hour Holter device,” he concluded.

References

1. Higgins P, MacFarlane PW, Dawson J, McInnes GT, Langhorne P, Lees KR. Noninvasive cardiac event monitoring to detect atrial fibrillation after ischemic stroke: a randomized controlled trial. Stroke 2013. http://dx.doi.org/10.1161/​STROKEAHA.113.001927

Published on: August 30, 2013

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ENDORSED BY

  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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