David J Gladstone1, Paul Dorian2, Melanie Spring2, Val Panzov2, Muhammad Mamdani2, Jeff S Healey2, Kevin E Thorpe2. 1. From the Division of Neurology (D.J.G.), Department of Medicine (D.J.G., P.D., M.S., M.M.), and Dalla Lana School of Public Health (K.E.T.), University of Toronto, Toronto, Ontario, Canada; University of Toronto Stroke Program, Toronto, Ontario, Canada (D.J.G.); Division of Neurology, Department of Medicine, and the Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada (D.J.G.); Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada (D.J.G.); Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (M.M., V.P., K.E.T.); and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.). david.gladstone@sunnybrook.ca. 2. From the Division of Neurology (D.J.G.), Department of Medicine (D.J.G., P.D., M.S., M.M.), and Dalla Lana School of Public Health (K.E.T.), University of Toronto, Toronto, Ontario, Canada; University of Toronto Stroke Program, Toronto, Ontario, Canada (D.J.G.); Division of Neurology, Department of Medicine, and the Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada (D.J.G.); Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada (D.J.G.); Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (M.M., V.P., K.E.T.); and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.).
Abstract
BACKGROUND AND PURPOSE: Many ischemic strokes or transient ischemic attacks are labeled cryptogenic but may have undetected atrial fibrillation (AF). We sought to identify those most likely to have subclinical AF. METHODS: We prospectively studied patients with cryptogenic stroke or transient ischemic attack aged ≥55 years in sinus rhythm, without known AF, enrolled in the intervention arm of the 30 Day Event Monitoring Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event (EMBRACE) trial. Participants underwent baseline 24-hour Holter ECG poststroke; if AF was not detected, they were randomly assigned to 30-day ECG monitoring with an AF auto-detect external loop recorder. Multivariable logistic regression assessed the association between baseline variables (Holter-detected atrial premature beats [APBs], runs of atrial tachycardia, age, and left atrial enlargement) and subsequent AF detection. RESULTS: Among 237 participants, the median baseline Holter APB count/24 h was 629 (interquartile range, 142-1973) among those who subsequently had AF detected versus 45 (interquartile range, 14-250) in those without AF (P<0.001). APB count was the only significant predictor of AF detection by 30-day ECG (P<0.0001), and at 90 days (P=0.0017) and 2 years (P=0.0027). Compared with the 16% overall 90-day AF detection rate, the probability of AF increased from <9% among patients with <100 APBs/24 h to 9% to 24% in those with 100 to 499 APBs/24 h, 25% to 37% with 500 to 999 APBs/24 h, 37% to 40% with 1000 to 1499 APBs/24 h, and 40% beyond 1500 APBs/24 h. CONCLUSIONS: Among older cryptogenic stroke or transient ischemic attack patients, the number of APBs on a routine 24-hour Holter ECG was a strong dose-dependent independent predictor of prevalent subclinical AF. Those with frequent APBs have a high probability of AF and represent ideal candidates for prolonged ECG monitoring for AF detection. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00846924.
RCT Entities:
BACKGROUND AND PURPOSE: Many ischemic strokes or transient ischemic attacks are labeled cryptogenic but may have undetected atrial fibrillation (AF). We sought to identify those most likely to have subclinical AF. METHODS: We prospectively studied patients with cryptogenic stroke or transient ischemic attack aged ≥55 years in sinus rhythm, without known AF, enrolled in the intervention arm of the 30 Day Event Monitoring Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event (EMBRACE) trial. Participants underwent baseline 24-hour Holter ECG poststroke; if AF was not detected, they were randomly assigned to 30-day ECG monitoring with an AF auto-detect external loop recorder. Multivariable logistic regression assessed the association between baseline variables (Holter-detected atrial premature beats [APBs], runs of atrial tachycardia, age, and left atrial enlargement) and subsequent AF detection. RESULTS: Among 237 participants, the median baseline Holter APB count/24 h was 629 (interquartile range, 142-1973) among those who subsequently had AF detected versus 45 (interquartile range, 14-250) in those without AF (P<0.001). APB count was the only significant predictor of AF detection by 30-day ECG (P<0.0001), and at 90 days (P=0.0017) and 2 years (P=0.0027). Compared with the 16% overall 90-day AF detection rate, the probability of AF increased from <9% among patients with <100 APBs/24 h to 9% to 24% in those with 100 to 499 APBs/24 h, 25% to 37% with 500 to 999 APBs/24 h, 37% to 40% with 1000 to 1499 APBs/24 h, and 40% beyond 1500 APBs/24 h. CONCLUSIONS: Among older cryptogenic stroke or transient ischemic attack patients, the number of APBs on a routine 24-hour Holter ECG was a strong dose-dependent independent predictor of prevalent subclinical AF. Those with frequent APBs have a high probability of AF and represent ideal candidates for prolonged ECG monitoring for AF detection. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00846924.
Authors: Karl Georg Haeusler; Klaus Gröschel; Martin Köhrmann; Stefan D Anker; Johannes Brachmann; Michael Böhm; Hans-Christoph Diener; Wolfram Doehner; Matthias Endres; Christian Gerloff; Hagen B Huttner; Manfred Kaps; Paulus Kirchhof; Darius Günther Nabavi; Christian H Nolte; Waltraud Pfeilschifter; Burkert Pieske; Sven Poli; Wolf Rüdiger Schäbitz; Götz Thomalla; Roland Veltkamp; Thorsten Steiner; Ulrich Laufs; Joachim Röther; Rolf Wachter; Renate Schnabel Journal: Clin Res Cardiol Date: 2018-04-27 Impact factor: 5.460