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Circulation: Arrhythmia and Electrophysiology

Clinical Articles, Lead Article

Longer ECG monitoring after stroke a must

Longer duration of electrocardiographic monitoring after cryptogenic stroke is associated with a greater detection of atrial fibrillation (AF), according to a study published recently in Circulation: Arrhythmia and Electrophysiology.1

While standard investigations following an event include electrocardiographic (ECG) monitoring, the optimal duration to detect AF is unclear. The authors performed a systematic review and meta-analysis to determine whether the duration of ECG-monitoring following an ischaemic event is related to the detection of AF.

Prospective studies that reported the proportion of new AF diagnosed using ECG-monitoring for greater than 12 hours in patients with recent stroke or transient ischaemic attack (TIA) were analysed. Studies were excluded if the stroke was haemorrhagic or AF was previously diagnosed. A total of 31 articles met inclusion criteria. Longer duration of monitoring was associated with an increased detection of AF when examining monitoring time as a continuous variable (p<0.001 for meta-regression analysis).

When dichotomising studies based on monitoring duration, studies with monitoring lasting ≤72 hours detected AF in 5.1% whereas monitoring lasting ≥7 days detected AF in 15%. The proportion of new diagnosis increased to 29.15% with extended monitoring for three months. Significant heterogeneity within studies was detected for both groups (≤72 hours: I2 = 91.3%; ≥7 days: I2 = 75.8). When assessing the odds of AF detection in the three randomised controlled trial, there was a 7.26 increased odds of AF with long-term monitoring (95% CI [3.99-12.83]; p-value <0.001).

Dr Charles Dussault (Sherbrooke University, Quebec, Canada)

Dr Charles Dussault (Sherbrooke University, Quebec, Canada)

Future investigation is needed to determine the optimal duration of long-term monitoring, say the authors.

Speaking to BJC Arrhythmia Watch, Dr Charles Dussault (Sherbrooke University, Quebec, Canada) said: “Our results suggest that extending electrocardiographic monitoring for up to six months following cryptogenic stroke will increase significantly the proportion of patients diagnosed with AF. While we may be tempted to implant more loop-recorders following a stroke after a negative inpatient work-up, AF diagnosis remains a surrogate endpoint for these patients for whom the real objective is to prevent stroke recurrence”.

“This meta-analysis certainly suggests that we can do better in terms of AF screening after a stroke, but more specific evidence regarding the clinical impact as well as the cost-effectiveness of diagnosing and treating AF up to six months after a stroke are necessary before we can recommend routine loop-recorder implantation in these patients,” Dr Dussault added.

References

1. Dussault C, Toeg H, Nathan H, Wang ZJ, Roux JF, Secemsky E. Electrocardiographic monitoring for detecting atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Circ Arrhythm Electrophysiol 2015. http://dx.doi.org/10.1161/CIRCEP.114.002521

Published on: February 25, 2015

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