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Detection of Atrial Fibrillation in Cryptogenic Stroke

  • Karl Georg Haeusler
  • Serdar Tütüncü
  • Renate B. Schnabel
Stroke (H Diener, Section Editor)
  • 30 Downloads
Part of the following topical collections:
  1. Topical Collection on Stroke

Abstract

Purpose of Review

To summarize the literature on the detection of atrial fibrillation (AF) in patients with “cryptogenic” stroke, a cohort including about 25% of all ischemic stroke patients and patients with embolic stroke of undetermined source (ESUS).

Recent Findings

A first episode of AF is detected in up to one third of cryptogenic stroke and in up to one fourth of ESUS patients during long-term monitoring. AF prevalence correlates to patient selection, duration, and quality of ECG monitoring. Higher rates of AF were reported in stroke patients with left atrial pathology, specific ECG alterations, or increased natriuretic peptides. While AF detection impacts on medical stroke prevention in the vast majority of patients, patient selection for prolonged monitoring is largely left at the physician’s discretion.

Summary

AF detection after cryptogenic stroke or ESUS is a frequent, potentially causal condition. Whether subsequent oral anticoagulation may improve outcome remains open.

Keywords

Ischemic stroke Atrial fibrillation ECG monitoring Stroke unit Cryptogenic stroke Embolic stroke of undetermined source 

Notes

Compliance with Ethical Standards

Conflict of Interest

Karl Georg Haeusler has received grants and personal fees from Bayer and Sanofi, personal fees from Boehringer Ingelheim, Daiichi-Sankyo, Pfizer, BMS, Medtronic, EIP Pharma, Edwards Lifesciences, and non-financial support from Getemed.

Serdar Tütüncü has received lecture fees from DTN-Kompakt (meeting/conference).

Renate B. Schnabel has received a grant from the European Research Council, and personal fees from BMS/Pfizer and the German Cardiac Society.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    • Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37:2893–962.  https://doi.org/10.1093/eurheartj/ehw210. Present guidelines of the ESC/EACTS. CrossRefPubMedGoogle Scholar
  2. 2.
    Brachmann J, Morillo CA, Sanna T, Di Lazzaro V, Diener H, Bernstein RA, et al. Uncovering atrial fibrillation beyond short-term monitoring in cryptogenic stroke patients: three-year results from the cryptogenic stroke and underlying atrial fibrillation trial. Circ Arrhythm Electrophysiol. 2016;9:e003333.  https://doi.org/10.1161/CIRCEP.115.003333.CrossRefPubMedGoogle Scholar
  3. 3.
    Poli S, Diedler J, Härtig F, Götz N, Bauer A, Sachse T, et al. Insertable cardiac monitors after cryptogenic stroke--a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation. Eur J Neurol. 2016;23:375–81.  https://doi.org/10.1111/ene.12843.CrossRefPubMedGoogle Scholar
  4. 4.
    Herm J, Konieczny M, Jungehulsing GJ, Endres M, Villringer A, Malzahn U, et al. Should transesophageal echocardiography be performed in acute stroke patients with atrial fibrillation? J Clin Neurosci. 2013;20:554–9.  https://doi.org/10.1016/j.jocn.2012.03.049.CrossRefPubMedGoogle Scholar
  5. 5.
    Rizos T, Horstmann S, Dittgen F, Täger T, Jenetzky E, Heuschmann P, et al. Preexisting heart disease underlies newly diagnosed atrial fibrillation after acute ischemic stroke. Stroke. 2016;47:336–41.  https://doi.org/10.1161/STROKEAHA.115.011465.CrossRefPubMedGoogle Scholar
  6. 6.
    Hellwig S, Grittner U, Audebert H, Endres M, Haeusler KG. Non-vitamin K-dependent oral anticoagulants have a positive impact on ischaemic stroke severity in patients with atrial fibrillation. Europace. 2018;20:569–74.  https://doi.org/10.1093/europace/eux087.CrossRefPubMedGoogle Scholar
  7. 7.
    Grond M, Jauss M, Hamann G, Stark E, Veltkamp R, Nabavi D, et al. Improved detection of silent atrial fibrillation using 72-hour Holter ECG in patients with ischemic stroke: a prospective multicenter cohort study. Stroke. 2013;44:3357–64.  https://doi.org/10.1161/STROKEAHA.113.001884.CrossRefPubMedGoogle Scholar
  8. 8.
    Stahrenberg R, Weber-Krüger M, Seegers J, Edelmann F, Lahno R, Haase B, et al. Enhanced detection of paroxysmal atrial fibrillation by early and prolonged continuous holter monitoring in patients with cerebral ischemia presenting in sinus rhythm. Stroke. 2010;41:2884–8.  https://doi.org/10.1161/STROKEAHA.110.591958.CrossRefPubMedGoogle Scholar
  9. 9.
    Kishore A, Vail A, Majid A, Dawson J, Lees KR, Tyrrell PJ, et al. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke. 2014;45:520–6.  https://doi.org/10.1161/STROKEAHA.113.003433.CrossRefPubMedGoogle Scholar
  10. 10.
    Marini C, de Santis F, Sacco S, Russo T, Olivieri L, Totaro R, et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke. 2005;36:1115–9.  https://doi.org/10.1161/01.STR.0000166053.83476.4a.CrossRefPubMedGoogle Scholar
  11. 11.
    Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon David L, et al. Classification of subtype of acute ischemic stroke.: definitions for use in a multicenter clinical trial. Stroke. 1993;24:35–41.CrossRefPubMedGoogle Scholar
  12. 12.
    • Hart RG, Diener H, Coutts SB, Easton JD, Granger CB, O’Donnell MJ, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. 2014;13:429–38.  https://doi.org/10.1016/S1474-4422(13)70310-7. Position paper defining the term embolic stroke of undetermined source, further providing an excellent review of present knowledge. CrossRefPubMedGoogle Scholar
  13. 13.
    Diener H, Bernstein R, Hart R. Secondary stroke prevention in cryptogenic stroke and embolic stroke of undetermined source (ESUS). Curr Neurol Neurosci Rep. 2017;17:64.  https://doi.org/10.1007/s11910-017-0775-5.CrossRefPubMedGoogle Scholar
  14. 14.
    •• Hart RG, Sharma M, Mundl H, Kasner SE, Bangdiwala SI, Berkowitz SD, et al. Rivaroxaban for stroke prevention after embolic stroke of undetermined source. N Engl J Med. 2018;378:2191–201.  https://doi.org/10.1056/NEJMoa1802686. Randomized double-blind study reporting the results of the NAVIGATE ESUS trial, comparing rivaroxaban to acetylsalicylic acid in ESUS patients. CrossRefPubMedGoogle Scholar
  15. 15.
    Camm AJ, Simantirakis E, Goette A, Lip GYH, Vardas P, Calvert M, et al. Atrial high-rate episodes and stroke prevention. Europace. 2017;19:169–79.  https://doi.org/10.1093/europace/euw279.CrossRefPubMedGoogle Scholar
  16. 16.
    Gelder V, Isabelle C, Healey JS, Crijns HJGM, Wang J, Hohnloser SH, et al. Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT. Eur Heart J. 2017;38:1339–44.  https://doi.org/10.1093/eurheartj/ehx042.CrossRefPubMedGoogle Scholar
  17. 17.
    Ganesan AN, Chew DP, Hartshorne T, Selvanayagam JB, Aylward PE, Sanders P, et al. The impact of atrial fibrillation type on the risk of thromboembolism, mortality, and bleeding: a systematic review and meta-analysis. Eur Heart J. 2016;37:1591–602.  https://doi.org/10.1093/eurheartj/ehw007.CrossRefPubMedGoogle Scholar
  18. 18.
    • Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:2160–236.  https://doi.org/10.1161/STR.0000000000000024. Present guidelines of the AHA/ASA. CrossRefPubMedGoogle Scholar
  19. 19.
    Higgins P, Dawson J, MacFarlane PW, McArthur K, Langhorne P, Lees KR. Predictive value of newly detected atrial fibrillation paroxysms in patients with acute ischemic stroke, for atrial fibrillation after 90 days. Stroke. 2014;45:2134–6.  https://doi.org/10.1161/STROKEAHA.114.005405.CrossRefPubMedGoogle Scholar
  20. 20.
    Lubitz SA, Yin X, Rienstra M, Schnabel RB, Walkey AJ, Magnani JW, et al. Long-term outcomes of secondary atrial fibrillation in the community: the Framingham Heart Study. Circulation. 2015;131:1648–55.  https://doi.org/10.1161/CIRCULATIONAHA.114.014058.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    • Kamel H, Okin PM, Elkind MSV, Iadecola C. Atrial fibrillation and mechanisms of stroke: time for a new model. Stroke. 2016;47:895–900.  https://doi.org/10.1161/STROKEAHA.115.012004. Review summarizing present knowledge. PubMedPubMedCentralGoogle Scholar
  22. 22.
    Hur J, Kim YJ, Lee H, Nam JE, Hong YJ, Kim HY, et al. Cardioembolic stroke: dual-energy cardiac CT for differentiation of left atrial appendage thrombus and circulatory stasis. Radiology. 2012;263:688–95.  https://doi.org/10.1148/radiol.12111691.CrossRefPubMedGoogle Scholar
  23. 23.
    Friberg L, Rosenqvist M, Lip GYH. Net clinical benefit of warfarin in patients with atrial fibrillation: a report from the Swedish atrial fibrillation cohort study. Circulation. 2012;125:2298–307.  https://doi.org/10.1161/CIRCULATIONAHA.111.055079.CrossRefPubMedGoogle Scholar
  24. 24.
    Brambatti M, Connolly SJ, Gold MR, Morillo CA, Capucci A, Muto C, et al. Temporal relationship between subclinical atrial fibrillation and embolic events. Circulation. 2014;129:2094–9.  https://doi.org/10.1161/CIRCULATIONAHA.113.007825.CrossRefPubMedGoogle Scholar
  25. 25.
    Tahsili-Fahadan P, Geocadin RG. Heart-brain axis: effects of neurologic injury on cardiovascular function. Circ Res. 2017;120:559–72.  https://doi.org/10.1161/CIRCRESAHA.116.308446.CrossRefPubMedGoogle Scholar
  26. 26.
    • Sposato LA, Riccio PM, Hachinski V. Poststroke atrial fibrillation: cause or consequence? Critical review of current views. Neurology. 2014;82:1180–6.  https://doi.org/10.1212/WNL.0000000000000265. Review summarizing present knowledge. CrossRefPubMedGoogle Scholar
  27. 27.
    •• Sanna T, Diener H, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370:2478–86.  https://doi.org/10.1056/NEJMoa1313600. Randomized study reporting the prevalence of AF detection in patients with cryptogenic stroke. CrossRefPubMedGoogle Scholar
  28. 28.
    •• Gladstone DJ, Sharma M, Spence JD. Cryptogenic stroke and atrial fibrillation. N Engl J Med. 2014;371:1260.  https://doi.org/10.1056/NEJMc1409495. Randomized study reporting the prevalence of AF detection in patients with cryptogenic stroke. PubMedGoogle Scholar
  29. 29.
    Haeusler KG, Gröschel K, Köhrmann M, Anker SD, Brachmann J, Böhm M, et al. Expert opinion paper on atrial fibrillation detection after ischemic stroke. Clin Res Cardiol. 2018;  https://doi.org/10.1007/s00392-018-1256-9.
  30. 30.
    Sposato LA, Cipriano LE, Saposnik G, Ruíz Vargas E, Riccio PM, Hachinski V. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 2015;14:377–87.  https://doi.org/10.1016/S1474-4422(15)70027-X.CrossRefPubMedGoogle Scholar
  31. 31.
    Wallmann D, Tüller D, Wustmann K, Meier P, Isenegger J, Arnold M, et al. Frequent atrial premature beats predict paroxysmal atrial fibrillation in stroke patients: an opportunity for a new diagnostic strategy. Stroke. 2007;38:2292–4.  https://doi.org/10.1161/STROKEAHA.107.485110.CrossRefPubMedGoogle Scholar
  32. 32.
    Wachter R, Gröschel K, Gelbrich G, Hamann GF, Kermer P, Liman J, et al. Holter-electrocardiogram-monitoring in patients with acute ischaemic stroke (Find-AFRANDOMISED): an open-label randomised controlled trial. Lancet Neurol. 2017;16:282–90.  https://doi.org/10.1016/S1474-4422(17)30002-9.CrossRefPubMedGoogle Scholar
  33. 33.
    Israel C, Kitsiou A, Kalyani M, Deelawar S, Ejangue LE, Rogalewski A, et al. Detection of atrial fibrillation in patients with embolic stroke of undetermined source by prolonged monitoring with implantable loop recorders. Thromb Haemost. 2017;117:1962–9.  https://doi.org/10.1160/TH17-02-0072.CrossRefPubMedGoogle Scholar
  34. 34.
    Cotter PE, Martin PJ, Ring L, Warburton EA, Belham M, Pugh PJ. Incidence of atrial fibrillation detected by implantable loop recorders in unexplained stroke. Neurology. 2013;80:1546–50.  https://doi.org/10.1212/WNL.0b013e31828f1828.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Ritter MA, Kochhäuser S, Duning T, Reinke F, Pott C, Dechering DG, et al. Occult atrial fibrillation in cryptogenic stroke: detection by 7-day electrocardiogram versus implantable cardiac monitors. Stroke. 2013;44:1449–52.  https://doi.org/10.1161/STROKEAHA.111.676189.CrossRefPubMedGoogle Scholar
  36. 36.
    The European Stroke Organization (ESO) Executive Committee and the ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis. 2008;25:457–507.  https://doi.org/10.1159/000131083.
  37. 37.
    Bravata DM, Myers LJ, Arling G, Miech EJ, Damush T, Sico JJ, et al. Quality of care for veterans with transient ischemic attack and minor stroke. JAMA Neurol. 2018;75:419–27.  https://doi.org/10.1001/jamaneurol.2017.4648.CrossRefPubMedGoogle Scholar
  38. 38.
    Kallmünzer B, Breuer L, Hering C, Raaz-Schrauder D, Kollmar R, Huttner HB, et al. A structured reading algorithm improves telemetric detection of atrial fibrillation after acute ischemic stroke. Stroke. 2012;43:994–9.  https://doi.org/10.1161/STROKEAHA.111.642199.CrossRefPubMedGoogle Scholar
  39. 39.
    Rizos T, Güntner J, Jenetzky E, Marquardt L, Reichardt C, Becker R, et al. Continuous stroke unit electrocardiographic monitoring versus 24-hour Holter electrocardiography for detection of paroxysmal atrial fibrillation after stroke. Stroke. 2012;43:2689–94.  https://doi.org/10.1161/STROKEAHA.112.654954.CrossRefPubMedGoogle Scholar
  40. 40.
    Kurka N, Bobinger T, Kallmünzer B, Koehn J, Schellinger PD, Schwab S, et al. Reliability and limitations of automated arrhythmia detection in telemetric monitoring after stroke. Stroke. 2015;46:560–3.  https://doi.org/10.1161/STROKEAHA.114.007892.CrossRefPubMedGoogle Scholar
  41. 41.
    Uphaus T, Grings A, Gröschel S, Müller A, Weber-Krüger M, Wachter R, et al. Automatic detection of paroxysmal atrial fibrillation in patients with ischaemic stroke: better than routine diagnostic workup? Eur J Neurol. 2017;24:990–4.  https://doi.org/10.1111/ene.13326.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Tu HT, Chen Z, Swift C, Churilov L, Guo R, Liu X, et al. Smartphone electrographic monitoring for atrial fibrillation in acute ischemic stroke and transient ischemic attack. Int J Stroke. 2017;12:786–9.  https://doi.org/10.1177/1747493017696097.CrossRefPubMedGoogle Scholar
  43. 43.
    Dussault C, Toeg H, Nathan M, Wang ZJ, Roux J, Secemsky E. Electrocardiographic monitoring for detecting atrial fibrillation after ischemic stroke or transient ischemic attack: systematic review and meta-analysis. Circ Arrhythm Electrophysiol. 2015;8:263–9.  https://doi.org/10.1161/CIRCEP.114.002521.CrossRefPubMedGoogle Scholar
  44. 44.
    Thijs VN, Brachmann J, Morillo CA, Passman RS, Sanna T, Bernstein RA, et al. Predictors for atrial fibrillation detection after cryptogenic stroke: results from CRYSTAL AF. Neurology. 2016;86:261–9.  https://doi.org/10.1212/WNL.0000000000002282.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    • Gladstone DJ, Dorian P, Spring M, Panzov V, Mamdani M, Healey JS, et al. Atrial premature beats predict atrial fibrillation in cryptogenic stroke: results from the EMBRACE trial. Stroke. 2015;46:936–41.  https://doi.org/10.1161/STROKEAHA.115.008714. Substudy of a randomized study reporting the importance of atrial premature beats to detect AF in patients with cryptogenic stroke. CrossRefPubMedGoogle Scholar
  46. 46.
    Broughton ST, O’Neal WT, Salahuddin T, Soliman EZ. The influence of left atrial enlargement on the relationship between atrial fibrillation and stroke. J Stroke Cerebrovasc Dis. 2016;25:1396–402.  https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.02.004.CrossRefPubMedGoogle Scholar
  47. 47.
    Waldenhjort D, Sobocinski Doliwa P, Alam M, Frykman-Kull V, Engdahl J, Rosenqvist M, et al. Echocardiographic measures of atrial function may predict atrial fibrillation in stroke patients. Scand Cardiovasc J. 2016;50:236–42.  https://doi.org/10.1080/14017431.2016.1175657.CrossRefPubMedGoogle Scholar
  48. 48.
    Bernstein RA, Di Lazzaro V, Rymer MM, Passman RS, Brachmann J, Morillo CA, et al. Infarct topography and detection of atrial fibrillation in cryptogenic stroke: results from CRYSTAL AF. Cerebrovasc Dis. 2015;40:91–6.  https://doi.org/10.1159/000437018.CrossRefPubMedGoogle Scholar
  49. 49.
    Haeusler KG, Kirchhof P, Heuschmann PU, Laufs U, Busse O, Kunze C, et al. Impact of standardized MONitoring for Detection of Atrial Fibrillation in Ischemic Stroke (MonDAFIS): rationale and design of a prospective randomized multicenter study. Am Heart J. 2016;172:19–25.  https://doi.org/10.1016/j.ahj.2015.10.010.CrossRefPubMedGoogle Scholar
  50. 50.
    • Sposato LA, Cerasuolo JO, Cipriano LE, Fang J, Fridman S, Paquet M, et al. Atrial fibrillation detected after stroke is related to a low risk of ischemic stroke recurrence. Neurology. 2018;90:e924–31.  https://doi.org/10.1212/WNL.0000000000005126. Retrospective analysis of a large registry reporting the recurrent stroke rate in stroke patients with sinus rhythm, a first episode of AF after stroke, or known AF before stroke. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Karl Georg Haeusler
    • 1
    • 2
    • 3
    • 4
  • Serdar Tütüncü
    • 2
  • Renate B. Schnabel
    • 3
    • 5
    • 6
  1. 1.Department of NeurologyCharité – Universitätsmedizin BerlinBerlinGermany
  2. 2.Center for Stroke Research BerlinCharité – Universitätsmedizin BerlinBerlinGermany
  3. 3.Atrial Fibrillation NETwork (AFNET) e.VMünsterGermany
  4. 4.Department of Neurology, Universitätsklinikum WürzburgWürzburgGermany
  5. 5.Abteilung für Allgemeine und Interventionelle KardiologieUniversitäres Herzzentrum HamburgHamburgGermany
  6. 6.Deutsches Zentrum für Herz-Kreislauf-Forschung e.V. (DZHK)Partner Site Hamburg/Kiel/LübeckLübeckGermany

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