Supraventricular Runs in 7-Day Holter Monitoring Are Related to Increased Incidence of Atrial Fibrillation in a 3-Year Follow-Up of Cryptogenic Stroke Patients Free from Arrhythmia in a 24 h-Holter.

Andrzej Kułach,Michał Majewski,Zbigniew Gąsior,Milena Dewerenda,Anetta Lasek-Bal

doi:10.3390/jcdd8070081

Abstract

Introduction: Silent atrial fibrillation (AF) is a common cause of cryptogenic ischemic stroke (CIS). The 24-h-Holter is insufficient to reveal an occult arrhythmic cause of stroke and the strategy to select the patients for long-term monitoring is missing. Objectives: The aim of the study was to evaluate 7-day-Holter monitoring to identify cases with the arrhythmic cause of stroke in CIS patients in whom 24-h-Holter was free from arrhythmia, and to assess the relation between supraventricular (SV) runs in baseline Holter and the incidence of AF in a 3-year follow-up period. Methods: 78 patients (aged 60 ± 9 years, 45 males) with CIS and no arrhythmic findings in 24-h-Holter were enrolled. All patients had 7-day-Holter monitoring after stroke and were followed up for 36 months, and then 7-day Holter was repeated. We assessed SV runs (≥5 QRS) in the initial 7-day Holter and analyzed the relation of the findings with clinical characteristics of novel AF episodes revealed early after stroke and during a 3-year follow-up. Results: Baseline 7-day-Holter revealed SV runs in 36% of patients and AF in 9% of cases. During a 3-year follow-up, 8 additional cases were confirmed, both in standard care and in repeated Holter (a total of 19% of AF cases). There was no difference with regard to CHADS2VASc score (3.6 ± 1.1 vs. 3.4 ± 1.5; p = NS) and left atrium parameters between patients with SV runs and the non-arrhythmic group. Patients with SV runs had a higher incidence of AF both after stroke and in a 3-year follow-up (46% vs. 4%, RR 11.6, p < 0.001). In 8 cases, patent foramen ovale was detected during follow-up. Conclusions: A strategy of baseline 7-day-Holter monitoring after stroke allows for disclosing SV runs in every third case and AF in 9% of stroke survivors. Patients with SV runs have a higher incidence of AF (RR 11.6, p < 0.001) and should be considered for extended continuous ECG monitoring.

Highlights

Atrial fibrillation is a common arrhythmia, in older age, and the risk factors for atrial fibrillation (AF) are well defined, there are still no reliable tools that would predict the occurrence of AF in a particular patient with the accuracy that would justify taking preventive steps
Considering that AF is a leading preventable cause of recurrent stroke, active and prolonged screening for atrial fibrillation is crucial for further therapy and prognosis after cryptogenic stroke
As we reported in our previous paper [10], in stroke survivors with no arrhythmic findings in 24 h Holter, 7-day Holter monitoring revealed AF in up to 10% of cases and performs better than the guideline-recommended minimum: a 72 h monitoring

Summary

Introduction

The cause of an acute stroke remains unknown in 20–40% of cases [1]. As it has been recently proved, in many patients with cryptogenic ischemic stroke (CIS), the cause is attributable to undiagnosed, clinically silent atrial fibrillation (AF) [2,3]. AF can be found in 10% to more than 25% of cases, depending on the timing, duration, and method of monitoring [5], and in many cases, the arrhythmia is asymptomatic and likely to be undetected [6]. Considering that AF is a leading preventable cause of recurrent stroke, active and prolonged screening for atrial fibrillation is crucial for further therapy and prognosis after cryptogenic stroke

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