Skip to main content
Log in

Detection of atrial fibrillation using an implantable loop recorder following cryptogenic stroke: implications for post-stroke electrocardiographic monitoring

  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Purpose

Approximately 10–40% of strokes are cryptogenic (CS). Long-term electrocardiographic (ECG) monitoring has been recommended in these patients to search for atrial fibrillation (AF). An unresolved issue is whether ambulatory ECG (AECG) monitoring should be performed first, followed by an implantable loop recorder (ILR) if AECG monitoring is non-diagnostic, or whether long-term ECG monitoring should be initiated using ILRs from the onset. The purpose of this study was to assess, using an ILR, AF incidence in the first month after CS.

Methods

We enrolled consecutive CS patients referred for an ILR. All patients were monitored via in-hospital continuous telemetry from admission until the ILR (Medtronic [Minneapolis, MN] LINQ™) was implanted. The duration and overall burden of all AF episodes ≥ 2 min was determined.

Results

The cohort included 343 patients (68 ± 11 years, CHA2DS2-VASc 3.5 ± 1.7). The time between stroke and ILR was 3.7 ± 1.5 days. During the first 30 days, only 18 (5%) patients had AF. All episodes were paroxysmal, lasting from 2 min to 67 h and 24 min. The median AF burden was 0.85% (IQR 0.52, 10.75). During 1 year of follow-up, 67 (21%) patients had AF.

Conclusion

The likelihood of AF detection by an ILR in the first month post-CS is low. Thus, the diagnostic yield of 30 days of AECG monitoring is likely to be limited. These data suggest a rationale for proceeding directly to ILR implantation prior to hospital discharge in CS patients, as many have AF detected during longer follow-up.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Abbreviations

AECG:

Ambulatory electrocardiography

AF:

Atrial fibrillation

CI :

Confidence interval

CS :

Cryptogenic stroke

CT :

Computed tomography

ECG :

Electrocardiogram

ILR:

Implantable loop recorder

IQR:

Interquartile range

MCT:

Mobile cardiovascular telemetry

MRI:

Magnetic resonance imaging

MRA:

Magnetic resonance angiography

PFO:

Patent foramen ovale

TIA:

Transient ischemic attack

TTE:

Transthoracic echocardiogram

TEE:

Transesophageal echocardiogram

References

  1. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017;135:e146–603.

    Article  Google Scholar 

  2. Saver JL. Cryptogenic stroke. N Engl J Med. 2016;374:2065–74.

    Article  CAS  Google Scholar 

  3. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report from the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019.

  4. Musat DL, Milstein N, Mittal S. Implantable loop recorders for cryptogenic stroke (plus real-world atrial fibrillation detection rate with implantable loop recorders). Card Electrophysiol Clin. 2018;10:111–8.

    Article  Google Scholar 

  5. Mittal S, Movsowitz C, Steinberg JS. Ambulatory external electrocardiographic monitoring: Focus on atrial fibrillation. J Am Coll Cardiol. 2011;58:1741–9.

    Article  Google Scholar 

  6. Lee R, Mittal S. Utility and limitations of long-term monitoring of atrial fibrillation using an implantable loop recorder. Heart Rhythm. 2018;15:287–95.

    Article  Google Scholar 

  7. Brachmann J, Morillo CA, Sanna T, di Lazzaro V, Diener HC, 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.

    Article  PubMed  Google Scholar 

  8. Mittal S, Rogers J, Sarkar S, Koehler J, Warman EN, Tomson TT, et al. Real-world performance of an enhanced atrial fibrillation detection algorithm in an insertable cardiac monitor. Heart Rhythm. 2016;13:1624–30.

    Article  Google Scholar 

  9. Pürerfellner H, Pokushalov E, Sarkar S, Koehler J, Zhou R, Urban L, et al. P-wave evidence as a method for improving algorithm to detect atrial fibrillation in insertable cardiac monitors. Heart Rhythm. 2014;11:1575–83.

    Article  Google Scholar 

  10. Sanders P, Pürerfellner H, Pokushalov E, Sarkar S, di Bacco M, Maus B, et al. Performance of a new atrial fibrillation detection algorithm in a miniaturized insertable cardiac monitor: results from the reveal LINQ usability study. Heart Rhythm. 2016;13:1425–30.

    Article  Google Scholar 

  11. Gladstone DJ, Spring M, Dorian P, Panzov V, Thorpe KE, Hall J, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370:2467–77.

    Article  CAS  Google Scholar 

  12. Sanna T, Diener H-C, 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.

    Article  CAS  Google Scholar 

  13. Asaithambi G, Monita JE, Annamalai MR, Ho BM, Marino EH, Hanson SK. Prevalence of atrial fibrillation with insertable cardiac monitors in cryptogenic stroke: a single-center experience. J Electrocardiol. 2018;51:973–6.

    Article  Google Scholar 

  14. Albers GW, Bernstein RA, Brachmann J, Camm J, Easton JD, Fromm P, et al. Heart rhythm monitoring strategies for cryptogenic stroke: 2015 diagnostics and monitoring stroke focus group report. J Am Heart Assoc. 2016;5(3):e002944. https://doi.org/10.1161/JAHA.115.002944.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Tung CE, Su D, Turakhia MP, Lansberg MG. Diagnostic yield of extended cardiac patch monitoring in patients with stroke or TIA. Front Neurol. 2015;5:266.

    Article  Google Scholar 

  16. 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.

    Article  CAS  Google Scholar 

  17. Van Gelder IC, Healey J, Crijns H, et al. Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT. Eur Heart J. 2017;38:1339–44.

    Article  Google Scholar 

  18. Lopes RD, Ailings M, Connolly SJ, et al. Rationale and design of the apixaban for the reduction of thrombo-embolism in patients with device-detected sub-clinical atrial fibrillation (ARTESiA) trial. Am Heart J. 2017;189:137–45.

    Article  Google Scholar 

  19. Diamantopoulos A, Sawyer LM, Lip GY, et al. Cost-effectiveness of an insertable cardiac monitor to detect atrial fibrillation in patients with cryptogenic stroke. Int J Stroke. 2016;11(3):302–12.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Nicolle S. Milstein.

Ethics declarations

The study was conducted following good clinical practice guidelines; the protocol was approved by our Institutional Review Board.

Conflict of interest

James Allred, MD, is a consultant to Medtronic. Amber Seiler, NPC, is a consultant to Medtronic. Advay Bhatt, MD, is a consultant to Abbott and Medtronic. Suneet Mittal, MD, is a consultant to Medtronic. All other authors declare that they have no conflicts of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Milstein, N.S., Musat, D.L., Allred, J. et al. Detection of atrial fibrillation using an implantable loop recorder following cryptogenic stroke: implications for post-stroke electrocardiographic monitoring. J Interv Card Electrophysiol 57, 141–147 (2020). https://doi.org/10.1007/s10840-019-00628-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-019-00628-6

Keywords

Navigation