World Stroke Organization The Paper of The Month – June
19 Jun 2024Is timing of AF detection after ischaemic stroke or TIA important?
Is timing of AF detection after ischaemic stroke or TIA important?
By Prof. Dr. Anita Arsovska – WSA Associate Commissioning Editor
This article is a commentary on the following: Thakur M, Alsinbili A, Chattopadhyay R, Warburton EA, Khadjooi K, Induruwa I. Identifying the optimal time period for detection of atrial fibrillation after ischaemic stroke and TIA: An updated systematic review and meta-analysis of randomized control trials. International Journal of Stroke. 2023 Nov 30:17474930231215277.
Summary of the findings
The authors performed a systematic review and meta-analysis of randomized controlled trials (RCT) between 2012 and 2023 investigating “new” AF (nAF) detection after ischaemic stroke (IS) and transient ischaemic attack (TIA)(1). A total of eight RCTs with 5820 patients investigated rhythm monitoring after IS. Outcome measures were overall detection of nAF (control; (usual care) compared to intervention; (continuous cardiac monitoring >72 h)) and the time period in which nAF detection is highest (0–14 days, 15–90days, 91–180days, or 181–365days). The meta-analysis of the studies suggested that continuous cardiac monitoring was associated with a pooled odds ratio of 3.81 (95% CI 2.14 to 6.77), compared to usual care (control), for nAF detection. In the time period analysis, the odds ratio for nAF detection at 0–14days, 15–90days, 91–180days, 181–365days were 1.79 (1.24–2.58); 2.01 (0.63–6.37); 0.98 (0.16–5.90); and 2.92 (1.30–6.56), respectively. The authors concluded that there is an almost fourfold increase in nAF detection with continuous cardiac monitoring, compared to usual care. The results also demonstrate two statistically significant time periods in nAF detection; at 0–14days and 6–12months following monitoring commencement. These data support the utilization of different monitoring methods to cover both time periods and a minimum of 1year of monitoring to maximize nAF detection in patients after IS and TIA.
Commentary
The latest guidelines from the European Stroke Organisation (2023) advise a minimum of 48 hours of cardiac monitoring in stroke patients (1). While the effectiveness of extended cardiac monitoring is uncertain, such methods increase the likelihood of detecting AF that is subclinical/detected only by devices (2). Many guidelines recommend using an implantable loop recorder or more than 2 weeks of portable ECG monitoring for patients who have had embolic stroke of unknown origin (3). The blood biomarker midregional pro-atrial natriuretic peptide may assist in determining which patients should undergo prolonged monitoring (4). Prolonged cardiac rhythm monitoring in patients with IS without known AF would result in 1·3–1·5 million new diagnoses of AF per year (5, 6).
A recent review analyzed whether the use of prolonged cardiac rhythm monitoring was associated with reduced IS recurrence and found no solid evidence supporting this association (7). The authors proposed B²AD-RISK AFDAS (Burden/Biomarkers (BNP)-Left Atrium size- Demographics (age and sex)-RISK Atrial Fibrilation Detected After Stroke) approach that might help to estimate stroke recurrence risk and guide decision making on anticoagulation by enabling a personalised prevention strategy (7). The ultimate goal would be to identify patients at low risk, who might not benefit from anticoagulation at the time of the AF diagnosis, but who would still require a close follow-up since AF burden is generally progressive and the prevalence of risk factors and comorbidities increases with age (7).
From a clinician’s perspective, it appears important to differentiate whether AFDAS is a direct cause, induced by the stroke itself, or simply an incidental finding (8). AFDAS persistence and recurrence rates are unclear and the risk of stroke recurrence in stroke patients with AFDAS lasting <24 h remains unknown (8). Attention should be paid to cognitive dysfunction in AFDAS patients during follow-up (8).
Another recent meta-analysis compared the use of insertable cardiac monitor (ICM) versus non-ICM methods of cardiac monitoring in IS patients on the detection of AF and other clinical outcomes (9). They found that the use of ICM increased the detection rate of poststroke AF and the rate of anticoagulation initiation in ischemic stroke patients. However, this did not translate into a reduced incidence of recurrent ischemic stroke.
Recent survey from Sweden found differences in the clinical practice for AF screening after IS/TIA between stroke units, both in choice of AF screening methods as well as in monitoring durations and recommended an urgent need for evidence and evidence-based recommendations in this field (10).
Available risk scores have demonstrated moderate to good predictive accuracy and could help identify patients who would benefit from extended cardiac monitoring after acute IS (11).
Conclusion
Harmonized and proper identification of AFDAS type is important in order to adequately manage stroke patients. Further studies, including use of AI-driven diagnostic and prognostic tools are needed to identify low-risk and high- risk patients.
References
- Rubiera M, Aires A, Antonenko K, et al. European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. Eur Stroke J 2022; 7: VI.
- Seiffge DJ, Cancelloni V, Räber L, Paciaroni M, Metzner A, Kirchhof P, Fischer U, Werring DJ, Shoamanesh A, Caso V. Secondary stroke prevention in people with atrial fibrillation: treatments and trials. The Lancet Neurology. 2024 Apr 1;23(4):404-17.
- Gladstone DJ, Lindsay MP, Douketis J, et al. Canadian stroke best practice recommendations: secondary prevention of stroke update 2020. Can J Neurol Sci 2022; 49: 315–37.
- Schweizer J, Arnold M, König IR, et al. Measurement of midregional pro-atrial natriuretic peptide to discover atrial fibrillation in patients with ischemic stroke. J Am Coll Cardiol 2022; 79: 1369–81.
- Thakur M, Alsinbili A, Chattopadhyay R, Warburton EA, Khadjooi K, Induruwa I. Identifying the optimal time period for detection of atrial fibrillation after ischaemic stroke and TIA: An updated systematic review and meta-analysis of randomized control trials. International Journal of Stroke. 2023 Nov 30:17474930231215277.
- Sposato LA, Chaturvedi S, Hsieh CY, Morillo CA, Kamel H. Atrial fibrillation detected after stroke and transient ischemic attack: a novel clinical concept challenging current views. Stroke. 2022 Mar;53(3):e94-103.
- Sposato LA, Field TS, Schnabel RB, Wachter R, Andrade JG, Hill MD. Towards a new classification of atrial fibrillation detected after a stroke or a transient ischaemic attack. The Lancet Neurology. 2024 Jan 1;23(1):110-22.
- Sposato LA, Lip GY, Haeusler KG. Atrial fibrillation first detected after stroke: is timing and detection intensity relevant for stroke risk?. European Heart Journal. 2024 Feb 1;45(5):396-8.
- Wong ZY, Yuen LZ, Tan YK, Goh CX, Teo YN, Ho JS, Seow SC, Lee EC, Teoh HL, Yeo LL, Sia CH. Detection of Atrial Fibrillation after Ischemic Stroke with an Insertable Cardiac Monitor: A Systematic Review and Individual Patient Data Meta-Analysis of Randomized Clinical Trials. Cerebrovascular Diseases. 2024 Jun 3;53(3):316-26.
- Strååt K, Isaksson E, Laska AC, Rooth E, Svennberg E, Åsberg S, Wester P, Engdahl J, AF SPICE steering committee. Large variations in atrial fibrillation screening practice after ischemic stroke and transient ischemic attack in Sweden: a survey study. BMC neurology. 2024 Apr 11;24(1):120.
- Kazemian S, Zarei D, Bozorgi A, Nazarian S, Issaiy M, Tavolinejad H, Tabatabaei-Malazy O, Ashraf H. Risk scores for prediction of paroxysmal atrial fibrillation after acute ischemic stroke or transient ischemic attack: A systematic review and meta-analysis. International Journal of Cardiology Cardiovascular Risk and Prevention. 2024 Feb 23:200249.
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