Second look Holter ECG in neurorehabilitation

Stefan Knecht,Paulus Kirchhof,Sebastian Petsch,Bettina Studer

doi:10.1186/s42466-019-0046-9

Abstract

BackgroundMany stroke survivors suffer recurrent stroke because paroxysmal atrial fibrillation (AF) was missed and no preventive anticoagulation initiated. This prospective cohort study determined the added diagnostic yield of second-look 24-h electrocardiographic recording (ECG) in a population at high risk for AF: patients who suffered a stroke of such severity that they require inpatient neurorehabilitation.MethodsWe enrolled 508 patients with ischemic stroke admitted to post-acute inpatient neurorehabilitation and determined whether AF was detected during acute care at the referring hospital. Second-look baseline and 24-h Holter ECG were then conducted during neurorehabilitation. Primary outcome was number of newly detected AF with duration of > 30 s; secondary outcomes were number of newly detected absolute arrhythmia of 10–30 s and < 10 s duration. For comparison, we further enrolled 100 patients with hemorrhagic stroke without history of AF (age = 72 + 11 years, 51% female).ResultsIn 206 of the 508 ischemic stroke patients, AF had been detected during acute phase work-up (age = 78 + 10 years, 55% female). For the remaining 302 ischemic stroke patients, no AF was detected during acute phase work-up (age = 74 + 9 years; 47% female). Second-look 24-h ECG showed previously missed AF of > 30 s in 20 of these patients, i.e. 6.6% of the sample, and shorter absolute arrhythmia in 50 patients (i.e. 16.5%).ConclusionsSecond-look 24-Hour ECG performed during post-acute inpatient neurorehabilitation has a high diagnostic yield and should become a standard component of recurrent stroke prevention.

Highlights

Atrial fibrillation (AF) is the leading preventable cause of recurrent stroke but escapes detection when paroxysmal
The current study investigated the diagnostic yield of a 2nd-look 24-h electrocardiographic recording (ECG) conducted during post-acute inpatient neurorehabilitation
A diagnosis of atrial fibrillation (AF) had been established in 206 of patients with ischemic stroke, whereas no AF had been detected during acute care in the remaining 302 of patients with ischemic stroke

Summary

Methods

The study was performed in a single inpatient neurorehabilitation center (Mauritius Hospital Meerbusch, Germany) with 200 beds serving a catchment area of approximately 2.8 million people. Admission criteria to inpatient neurorehabilitation are substantial functional deficits corresponding to a modified Rankin score of three or worse attributable to acute neurological disease with a potential for improvement. We prospectively included consecutive patients with ischemic or hemorrhagic strokes over an 18-months period. All survivors of acute ischemic or hemorrhagic stroke admitted to our center after hospital-based acute care were enrolled and recruitment was terminated once the pre-specified recruitment target of 600 patients was met. Holter ECG was conducted using a commercially available 3-lead Holter monitor device (Custo-med GmbH, Germany). ECG recordings were analyzed by independent expert investigators, and blinded to clinical data using dedicated analysis software (custo-med GmbH for Windows, Version 4.3.1 Build 18,597). The funder was not involved in the design or conduct of the study or the preparation of this manuscript (Fig. 1)

Results

Introduction

Discussion

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