Abstract
BackgroundThe cardiac diagnostic workup of stroke patients, especially the value of echocardiography and enhanced and prolonged Holter-ECG monitoring, is still a matter of debate. We aimed to analyse the impact of pathologies detected by echocardiography and ECG monitoring on therapeutic decisions and prognosis.MethodsFind-AFRANDOMISED was a prospective multicenter study which randomised 398 acute ischemic stroke patients ≥ 60 years to enhanced and prolonged Holter-ECG monitoring or usual stroke unit care. This substudy compared therapeutic consequences of echocardiography and routine Holter-ECG or enhanced and prolonged Holter-ECG monitoring, respectively, and prognosis of patients with or without pathologic findings in echocardiography or Holter-ECG monitoring.Results50.3% received enhanced and prolonged Holter-ECG monitoring and 49.7% routine ECG monitoring. 82.9% underwent transthoracic echocardiography (TTE), 38.9% transesophageal echocardiography (TEE) and 25.6% both procedures. 14/89 TEE pathologies and 1/90 TTE pathology led to a change in therapy, resulting in a number needed to change decision (NNCD) of 12 and 330 (p < 0.001), respectively. In comparison, enhanced and prolonged Holter-ECG monitoring found atrial fibrillation (AF) in 27 of 200 patients, and routine ECG monitoring in twelve of 198 patients, leading to therapeutic changes in all patients (NNCD 8 and 17, respectively, p < 0.001).ConclusionsMost changes in therapeutic decisions were triggered by enhanced and prolonged Holter-ECG monitoring, which should therefore play a more prominent role in future guidelines. Echocardiography identifies a patient group at high cardiovascular risk, but rarely result in therapeutic changes. Whether this patient group requires further cardiovascular workup remains unknown. This should be further investigated by interdisciplinary neurocardiologic teams and in appropriate future trials.Trial registrationClinicalTrials.gov NCT01855035
Highlights
Oral anticoagulation using Vitamin-K antagonists has been shown to decrease the risk of ischemic stroke by two thirds (Hart et al 2007) and newer drugs may be even more effective (Connolly et al 2009)
Registry data suggest that paroxysmal atrial fibrillation is largely underrepresented in anticoagulation trials and the risk of stroke and thromboembolism in paroxysmal Atrial fibrillation (AF) is less well defined (The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC) 2010)
Recent data suggest that the risk of stroke in paroxysmal atrial fibrillation is similar to persistent or permanent atrial fibrillation (Hohnloser et al 2007, Friberg et al 2010)
Summary
Atrial fibrillation (AF) is the most frequent arrhythmia and may be classified as paroxysmal, persistent and permanent. While persistent and permanent atrial fibrillation is diagnosed using a 12-lead ECG, the diagnosis of paroxysmal atrial fibrillation is more challenging. Registry data suggest that paroxysmal atrial fibrillation is largely underrepresented in anticoagulation trials and the risk of stroke and thromboembolism in paroxysmal AF is less well defined (The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC) 2010). Recent data suggest that the risk of stroke in paroxysmal atrial fibrillation is similar to persistent or permanent atrial fibrillation (Hohnloser et al 2007, Friberg et al 2010). Detection of paroxysmal atrial fibrillation is a major challenge in primary and secondary stroke prevention. Recent costeffectiveness analyses found that prolonged (7 day) Holter ECG after cerebral ischemia saves 1 quality adjusted life year (QALY) at the price of only $ 15.000 (Kamel et al 2010), or possibly even less (Wachter et al 2011)
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