Rhythm monitoring strategies for atrial fibrillation detection in patients with cryptogenic stroke: A systematic review and meta-analysis

Jean Jacques Noubiap; Thomas A Agbaedeng; Joseph Kamtchum-Tatuene; John L Fitzgerald; Melissa E Middeldorp; Timothy Kleinig; Prashanthan Sanders

doi:10.1016/j.ijcha.2021.100780

Rhythm monitoring strategies for atrial fibrillation detection in patients with cryptogenic stroke: A systematic review and meta-analysis

Int J Cardiol Heart Vasc. 2021 Apr 16:34:100780. doi: 10.1016/j.ijcha.2021.100780. eCollection 2021 Jun.

Authors

Jean Jacques Noubiap¹, Thomas A Agbaedeng¹, Joseph Kamtchum-Tatuene², John L Fitzgerald^{1

3}, Melissa E Middeldorp^{1

3}, Timothy Kleinig^{4

5}, Prashanthan Sanders^{1

3}

Affiliations

¹ Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia.
² Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
³ Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia.
⁴ Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia.
⁵ Adelaide Medical School, The University of Adelaide, Adelaide, Australia.

Abstract

Objective: To summarize data on atrial fibrillation (AF) detection rates and predictors across different rhythm monitoring strategies in patients with cryptogenic stroke (CS) or embolic stroke of undetermined source (ESUS).

Methods: MEDLINE, Embase, and Web of Science were searched to identify all published studies providing relevant data through July 6, 2020. Random-effects meta-analysis method was used to pool estimates.

Results: We included 47 studies reporting on a pooled population of 8,215 patients with CS or ESUS. Using implantable cardiac monitor (ICM), the pooled rate of AF was 12.2% (95% CI 9.4-15.0) at 3 months, 16.0% (95% CI 13.2-18.8) at 6 months, 18.7% (95% CI 15.7-21.7) at 12 months, 22.8% (95% CI 19.1-26.5) at 24 months, and 28.5% (95% CI 17.6-39.3) at 36 months. AF rates were significantly higher in patients with ESUS vs CS (22.0% vs 14.2%; p < 0.001) at 6 months, and in studies using Reveal LINQ vs Reveal XT ICM (19.1% vs 13.0%; p = 0.001) at 12 months. Using mobile cardiac outpatient telemetry (MCOT), the pooled rate of AF was 13.7% (95% CI 10.2-17.2) at 1 month. Predictors of AF detection with ICM included older age, CHA₂DS₂-VASc score, left atrial enlargement, P wave maximal duration and prolonged PR interval.

Conclusion: The yield of ICM increases with the duration of monitoring. More than a quarter of patients with CS or ESUS will be diagnosed with AF during follow-up. About one in seven patients had AF detected within a month of MCOT, suggesting that a non-invasive rhythm monitoring strategy should be considered before invasive monitoring.

Keywords: Atrial fibrillation; Cryptogenic stroke; Embolic stroke of undetermined source; Holter; Insertable cardiac monitor; Telemetry.