Detection Rate Of Atrial Fibrillation Research Articles

The Role of 24-Hour Holter Electrocardiogram in the Early Detection of Atrial Fibrillation in Newly Diagnosed Acute Ischemic Stroke Patients.

Introduction Stroke is a leading cause of death and disability globally, with atrial fibrillation (AF) recognized as a significant risk factor due to its association with increased stroke recurrence and mortality. Timely detection of AF is crucial to prevent recurrent strokes and improve outcomes. This study primarily aimed to evaluate the utility of 24-hour Holter monitoring for AF detection in acute ischemic stroke patients. Methods This retrospective observational study examined data from 207 patients admitted with acute ischemic stroke to a tertiary-care hospital over a two-year period. Patients with pre-existing AF, transient ischemic attacks, unconfirmed diagnoses, and missing Holter reports were excluded. A total of 140 patients were included in the analysis. The study investigated AF detection rates, the relationship between AF and stroke risk factors, other Holter findings, and the time delay in attaching Holter monitors. Results Of the 140 patients evaluated, AF was detected in nine (6.4%), exclusively in those aged ≥65 years. The most prevalent risk factors among the study participants were hypertension (74.3%) and diabetes (61.4%). No significant correlations were observed between AF and the analyzed stroke risk factors. The median delay for Holter device attachment was 3,503 minutes (approximately two days and 10 hours), with longer delays noted in males (4,084 mins (approximately two days and 20 hours) vs. 2,565 mins (approximately one day and 18 hours), p=0.005). Premature atrial complexes(PACs) were notably associated with the absence of AF, suggesting their potential role as markers for undiagnosed AF. Conclusion The study highlights the limited utility of 24-hour Holter monitoring in detecting AF in acute ischemic stroke patients, advocating for extended monitoring durations, especially in older patients. To improve AF detection, potential strategies include using longer monitoring periods and optimizing hospital workflows to reduce delays in attaching Holter devices. These approaches can minimize the risk of underdiagnosing paroxysmal AF, thereby preventing recurrent strokes and improving patient outcomes. Further investigation into PACs as potential predictive markers for AF is warranted.

Post-operative atrial fibrillation after noncardiac surgery: diagnostic role of ambulatory rhythm monitoring for recurrent arrhythmia after hospital discharge

Abstract Introduction Postoperative atrial fibrillation (POAF) after noncardiac surgery constitutes 10-15% of all cases of incident atrial fibrillation (AF) in the community and has been associated with an increased risk of stroke. The risk of subsequent AF among patients with POAF is not well defined. Purpose To evaluate the role of systematic 30-day electrocardiographic (ECG) monitoring in the detection of AF recurrence after POAF. Methods In a prospective interventional study, patients who underwent major noncardiac surgeries and had new AF documented by ECG in the post-operative period between May 2022 and April 2023 were identified. For these patients, a 30-day ambulatory ECG monitor was recommended upon discharge, with final ordering deferred to the primary inpatient teams. Rates of recurrent AF of any duration detected by 30-day monitoring plus routine care versus routine care alone after the surgery were compared. Results Eighty-five patients with new-onset POAF were included (mean age 72 years, male 67%). Of these, 35 (41%) patients underwent up to 30 days [median 23 (IQR 6-27) days] of continuous ECG monitoring after hospital discharge. There were no significant differences in baseline characteristics between patients who did or did not undergo monitoring (Table 1). During median 281 (IQR 197-385) days of follow-up, recurrent AF was documented in 14/35 (40%) patients in the monitoring group as opposed to 7/50 (14%) patients in the usual care group (log-rank p=0.003, Figure 1). The median time from day of surgery until documented AF recurrence was 25 (IQR 6-53) days in the monitoring group and 66 (IQR 25-145) in the usual care group. Overall, 81% of recurrent AF events in both groups were detected in the first 3 months after surgery. The median burden of AF in the cardiac monitoring group was 7% (IQR 1-15), with the longest AF event lasting a median of 6 (IQR 2-18) hours. Anticoagulation for AF was prescribed in 24/64 (37%) patients with POAF without recurrence and in 16/21 (76%) patients with recurrent AF. Conclusion Recurrent AF following POAF is common and detected most frequently in the first 3 months after noncardiac surgery. Systematic ambulatory rhythm monitoring is associated with a higher rate of AF detection following hospital discharge and may identify a patient subgroup who might benefit from anticoagulation therapy.Table 1Figure 1

Electrocardiogram prediction of atrial fibrillation risk after stroke: A protocol for systematic review and meta-analysis.

Atrial fibrillation (AF) is one of the most common clinical arrhythmias. This study aims to predict the risk of post-stroke AF through electrocardiographic changes in sinus rhythm. We searched the MEDLINE (PubMed) and EMBASE databases to identify relevant research articles published until August 2023. Prioritized items from systematic reviews and meta-analyses were screened, and data related to AF detection rate were extracted. A meta-analysis using a random-effects model was conducted for data synthesis and analysis. A total of 32 studies involving electrocardiograms (ECG) were included, with a total analysis population of 330,284 individuals. Among them, 16,662 individuals (ECG abnormal group) developed AF, while 313,622 individuals (ECG normal group) did not. ECG patterns included terminal P-wave terminal force V1, interatrial block (IAB), advanced interatrial block, abnormal P-wave axis, pulse rate prolongation, and atrial premature complexes. Overall, 15,762 patients experienced AF during the study period (4.77%). In the ECG abnormal group, the proportion was 14.21% (2367/16,662), while in the control group (ECG normal group), the proportion was 4.27% (13,395/313,622). The pooled risk ratio for developing AF was 2.45 (95% confidence interval [CI]: 2.02-2.98, P < .001), with heterogeneity (I2) of 95%. The risk ratio values of alAB, P-wave terminal force V1, interatrial block, abnormal P-wave axis, pulse rate prolongation and atrial premature complexes were 4.12 (95% CI, 2.99-5.66), 1.47 (95% CI, 1.19-1.82), 2.54 (95% CI, 1.83-3.52), 1.70 (95% CI, 0.98-2.97), 2.65 (95% CI, 1.88-3.72), 3.79 (95% CI, 2.12-6.76), respectively. There is a significant correlation between ECG patterns and the occurrence of AF. The alAB exhibited the highest level of predictability for the occurrence of AF. These indicators support their use as screening tools to identify high-risk individuals who may benefit from further examinations or empirical anticoagulation therapy following stroke.

The feasibility of population screening for paroxysmal atrial fibrillation using hand-held electrocardiogram devices.

There are few data on the feasibility of population screening for paroxysmal atrial fibrillation (AF) using hand-held electrocardiogram (ECG) devices outside a specialist setting or in people over the age of 75. We investigated the feasibility of screening when conducted without face-to-face contact ('remote') or via in-person appointments in primary care and explored impact of age on screening outcomes. People aged ≥65 years from 13 general practices in England participated in screening during 2019-20. This involved attending a practice nurse appointment (10 practices) or receiving an ECG device by post (three practices). Participants were asked to use a hand-held ECG for 1-4 weeks. Screening outcomes included uptake, quality of ECGs, AF detection rates, and uptake of anticoagulation if AF was detected. Screening was carried out by 2141 (87.5%) of people invited to practice nurse-led screening and by 288 (90.0%) invited to remote screening. At least 56 interpretable ECGs were provided by 98.0% of participants who participated for 3 weeks, with no significant differences by setting or age, except people aged 85 or over (91.1%). Overall, 2.6% (64/2429) screened participants had AF, with detection rising with age (9.2% in people aged 85 or over). A total of 53/64 (82.8%) people with AF commenced anticoagulation. Uptake of anticoagulation did not vary by age. Population screening for paroxysmal AF is feasible in general practice and without face-to-face contact for all ages over 64 years, including people aged 85 and over.

Impact of CHA2DS2-VASc score on smartphone-based screening for atrial fibrillation: A pre-specified subgroup analysis of the eBRAVE-AF trial

Abstract Background The eBRAVE-AF trial showed that digital smart-device based screening for atrial fibrillation (AF) more than doubled the detection rate of treatment-relevant AF when compared to usual care. Purpose In this pre-specified subgroup analysis, we investigated the effect of CHA2DS2-VASc score on compliance, efficacy of digital screening, and the interaction of CHA2DS2-VASc score and AF-triggered major adverse cardiovascular complications (MACCE). Methods 5.551 individuals, free of AF were randomized to digital screening (n=2.860) or usual care (n=2.691). For digital screening, participants used a certified app to screen for irregularities in their pulse waves by means of photoplethysmography (PPG). Abnormal findings were confirmed by a 14-day Holter-ECG. The primary endpoint was newly diagnosed AF treated with oral anticoagulation (OAC) within 6 months. After 6 months, participants crossed over to a second study phase with reverse assignment. For this analysis we combined the two phases using multilevel clustered Cox-regression analysis. CHA2DS2-VASc score was dichotomized at a cut-off of ≤ /&amp;gt; 3. Results The median CHA2DS2-VASc score was 3 ± 1, the median age was 65 ±11 years, 31% participants were females. Participants performed a median of 53 ± 62 PPG-measurements with no significant difference in participants with CHA2DS2-VASc score ≤ 3 (52 ± 61) and CHA2DS2-VASc score &amp;gt; 3 (54 ± 65, p=0.269). During a median follow-up time of 12 months 102 participants reached the primary endpoint (including 2 endpoints in the cross-over window). A CHA2DS2-VASc score &amp;gt; 3 (n=1.205; 33 events) compared to CHA2DS2-VASc score ≤ 3 (n=4.346; 69 events) was a significant predictor for reaching the primary endpoint (HR 1.78; 95% CI 1.18-2.70; p=0.006). Digital screening significantly increased the detection rate of AF requiring OAC in participants with CHA2DS2-VASc score &amp;gt; 3 (HR 2.11; 95% CI 1.00-4.42; p=0.049; Fig 1A) and CHA2DS2-VASc score ≤ 3 (HR 2.43; 95% CI 1.43-4.13; p=0.001; Fig 1B). There was no interaction (p=0.758) between CHA2DS2-VASc score and the efficacy of digital screening. The rate of MACCE in participants with CHA2DS2-VASc score &amp;gt; 3 (5.2%; 95% CI 3.8-6.6%) and CHA2DS2-VASc score ≤ 3 (4.6%; 95% CI 4.0%-5.3%) was not significantly different (HR 1.14; 95% CI 0.76-1.71; p=0.539). However, only in participants with CHA2DS2-VASc score ≤ 3 MACCE were associated with previously diagnosed AF (HR 9.77; 95% CI 5.08-18.79; p&amp;lt;0.001 vs. 1.43; 95% CI 0.28-7.37; p=0.618 in participants with CHA2DS2-VASc score &amp;gt; 3; p-interaction=0.034). Conclusion In a large-scale clinical trial, comparing digital screening to usual care for detecting AF requiring OAC a CHA2DS2-VASc score &amp;gt;3 did not influence compliance but was associated with higher risk for developing AF requiring OAC. CHA2DS2-VASc score &amp;gt;3 was not associated with higher rate of MACCE. However, only in participants with CHA2DS2-VASc score ≤ 3, these MACCE were triggered by previously diagnosed AF.

Differences of women and men in smartphone-based screening for atrial fibrillation: a pre-specified subgroup analysis of the eBRAVE-AF trial

Abstract Background eBRAVE-AF, a siteless, randomized, controlled trial, showed that digital smart-device based screening for atrial fibrillation (AF) significantly increased the detection rate of treatment-relevant AF when compared to usual care. Purpose In this pre-specified subgroup analysis, we aimed to investigate the effect of sex on compliance, efficacy of digital screening, as well as the interaction between sex and AF-triggered major adverse cardiovascular complications (MACCE). Methods 5.551 individuals, free of AF at baseline were randomized to digital screening (n=2.860) or usual care (n=2.691). For digital screening, participants used a certified app to screen for irregularities in their pulse waves by means of photoplethysmography (PPG). Abnormal findings were confirmed by a 14-day Holter-ECG. The primary endpoint was newly diagnosed AF treated with oral anticoagulation (OAC) within 6 months. After 6 months, participants were invited to cross-over for a second study phase with reverse assignment. For this analysis we combined the two phases of the study using multilevel clustered Cox-regression analysis. Results The median age was 65 ± 11 years, the median CHA2DS2-VASc score was 3 ± 1 and 1.725 participants (31%) were females. Female sex was associated with better compliance in terms of more frequent PPG-measurements (57 ± 57) compared to male sex (50 ± 62; p&amp;lt;0.001). During a median follow-up time of 12 months 102 subjects reached the primary endpoint (including 2 endpoints in the cross-over window). Male sex (81 events) compared to female sex (21 events) was a significant predictor for reaching the primary endpoint (HR 1.74; 95% CI 1.08-2.82, p=0.023). While digital screening significantly increased the detection rate of AF requiring OAC in men (HR 2.48; 95% CI 1.52-4.05, p &amp;lt;0.001; Fig 1A), this effect did not reach the level of statistical significance in women (HR 1.83; 95% CI 0.74-4.54, p=0.193; Fig 1B), most probably due to the lower event-rate. The interaction between sex and the efficacy of digital screening was not statistically significant (p=0.563). Next to a higher incidence of AF in men (3.0% per year; 95% CI 2.4-4.5%) compared to women (1.8% per year; 95% CI 1.1%-2.4%; p=0.013), male participants were also at a higher risk for developing MACCE (106 vs. 20 events) (HR 2.57; 95% CI 1.57-4.20, p &amp;lt;0.001). AF was a significant predictor for developing MACCE in men (HR 6.52; 95% CI 3.42-12.43, p&amp;lt;0.001). Only one female participant with AF developed MACCE. Therefore, this analysis cannot be applied in females. Conclusion In a large-scale clinical trial, comparing digital screening to usual care for detecting AF requiring OAC, female sex was associated with better compliance to the study protocol and lower risk for developing AF requiring OAC. There was no significant interaction between sex and the efficacy of digital screening for detecting AF requiring OAC. In men, newly-diagnosed AF was associated with increased risk for MACCE.

Screening for atrial fibrillation by village doctors in rural areas of china: the jiangsu province rural community atrial fibrillation project

Abstract Background No study has systematically investigated the quality of long-term care delivered to the rural elderly with chronic diseases in China. Since atrial fibrillation (AF) is becoming an increasing burden on healthcare systems worldwide. Purpose We conducted an AF screening programme in rural elderly and evaluated healthcare efficiency led by the village doctors in China. Methods This cross-sectional study of the rural population aged ≥65 years was conducted from April to June 2019 in our towns of Jiangsu Province. AF was identified using 12-lead electrocardiography in the first-step (government-led health examination) and single-lead electrocardiography in the second-step (in-house AF screening). Questionnaire surveys were designed for the AF patients and their village doctors, respectively. Results Among the 31,342 registered subjects, 12,630 (40·3%) declined, 7,956 (25·3%) participated in the first-step and 10,756 (34·3%) in the second-step (Figure 1). The overall AF detection rate was 4·3% (810/18,712). Of the 810 patients with AF (mean age 76·1±5·9 years; 51·4% female), 51·5% had education level below primary school, 2·6% could use smartphone applications, and 8·1% lived with their children. Common risk factors were older age, men, hypertension, diabetes, prior stroke, vascular disease, and congestive heart failure. Among the 402 patients who were aware of AF, there were 367 were at high risk of stroke (CHA2DS2-VASc score ≥3 in women or ≥2 in men) and OAC was currently used in only 10·9% (40/367) of these (Figure 2). Only 17·6% (91/516) of patients with known hypertension had a resting blood pressure level &amp;lt;140/90 mmHg, and 6·0% (8/132) of patients with known diabetes had a fasting blood glucose level ≤6·1 mmol/L. Our questionnaire survey for village doctors showed that only 7·3% (9/122) reported having the knowledge or ability for providing integrated care AF management. Conclusions This screening project in rural villages identified AF in 4·3%, but AF management was suboptimal with low use of oral anticoagulation. The current village doctor-dominant rural healthcare system is far from delivering optimal standardized AF management for older patients in rural China. There is a urgent need to support these rural clinics and empower the village doctors in optimising the care of AF patients.The flow chart of this studyThe use of oral anticoagulation

Age-dependent detection of Atrial Fibrillation with implantable cardiac monitors in patients with cryptogenic stroke

Abstract Background Prolonged and intensified rhythm monitoring is recommended to detect atrial fibrillation (AF) in patients with cryptogenic stroke (CS). Continuous monitoring using implantable cardiac monitors (ICM) results in AF detection rates of up to 30%. Although higher age has been identified as an independent risk factor for AF in patients post CS, there are no specific recommendations for the implantation of ICM in younger patients. Furthermore, the temporal relationship between AF and recurrent stroke in patients with continuous monitoring is a relevant issue and scarcely investigated. Objectives (1)To analyze age-related AF rates in patients with CS and continuous rhythm monitoring using ICM. (2)To determine the rates of oral anticoagulation and recurrent strokes in patients with ICM-detected AF after CS. (3)To describe the temporal relationship of AF detection and recurrent stroke in these patients. Methods From 02/2014 to 11/2021, patients with CS provided with ICMs were systematically followed. All patients underwent 72-h ECG monitoring, transcranial doppler ultrasound and transthoracic echocardiography according to current guidelines prior to ICM insertion. Follow-up was performed by means of a regular outpatient presentation every three months and included medical history, physical examination, and interrogation of the ICM. AF was defined as any episode of absolute arrhythmia &amp;gt;30 seconds. Results One hundred and eighty-six patients (mean age 65 ± 12 years) were included in this analysis. AF was detected in 62 patients (33 %) during a mean follow-up of 36 ± 23 months. AF was found in 6 % (3/52), 27 % (17/62), 56 % (31/55) and 65 % (11/17) (p &amp;lt; 0.001) in patients aged &amp;lt; 60 years, 60-69 years, 70-79 years and ≥ 80 years, respectively (see Figure 1). All patients with AF under 60 years had an impaired systolic left ventricular function (left ventricular ejection fraction &amp;lt; 50 %). Oral anticoagulation was initiated in 85% of the patients with AF. Recurrent stroke occurred in 34 patients (18.3%) of whom fifteen had a diagnosis of AF. In nine patients, AF was diagnosed before the occurrence of a recurrent stroke. In four patients, AF was diagnosed after recurrent stroke and in one patient, AF and recurrent stroke occurred simultaneously (see Figure 2). Conclusion AF was absent in cryptogenic stroke patients with preserved ejection fraction and younger than 60 years. AF prevalence increased with age. The temporal relationship of AF and recurrent stroke was weak. Further research is needed to better identify stroke patients at risk of AF and recurrent stroke. Figure 1: Time to first detection of Atrial fibrillation in patients aged &amp;lt; 60 years, 60-69 years, 70-79 years and ≥80 years, respectively. Figure 2: Temporal relationship of first detected atrial fibrillation (AF) and recurrent stroke in patients with cryptogenic stroke.Figure 1Figure 2

Apixaban for TreatmenT of embolIC stroke of Undetermined Source - ATTICUS randomized trial - explorative analysis of AF burden in the ATTICUS cohort

Abstract Background Secondary prevention after embolic stroke of undetermined source (ESUS) has not yet been established. It is likely that a relevant number of ESUS patients have significant episodes of atrial fibrillation (AF) that is not detected by conventional Holter ECGs. Despite high prevalence of occult atrial fibrillation , secondary prevention with acetylsalicylic acid (ASA) is the current standard therapy in ESUS patients. The ATTICUS cohort has been selected for prevalence of at least one suggestive risk factor for cardiac embolism (RF) creating an enriched ESUS population. Purpose This work aims to evaluate overall AF burden in the ATTICUS cohort; to determine the correlation between AF detection and new ischemic lesions; and to explore predictors for atrial fibrillation within the enriched ESUS population. Methods The study enrolled ESUS patients with a risk profile for cardiac thromboembolism. Patients were randomized 1:1 into the ASA or apixaban arm, respectively. Study drug was initiated within 3–28 days after minor/moderate stroke and 14–28 days after major stroke. Cardiac monitoring by either implantable or mobile ECG devices was required during the follow up period. MRI (Flair/DWI) was conducted within 7 days of AF detection and 12 months after randomization. Results Enrollment was stopped after interim analysis including 200 patients, due to futility. Overall, 373 patients were screened with 352 being enrolled in the ITT population (178 and 174 in apixaban and ASA arms, respectively). Mean age of the ATTICUS population was 68.4 years with 51.4% males. 86.1% of the subjects suffered from hypertension. 63.4% of the population showed only one RF, all others showed two or more RFs, whereof most common were CHA2DS2-VASc ≥ 4 (93.8%), PFO (20.5%) and atrial high-rate episodes (AHRE, 13.1%). Analysis of the correlation of AF with each suggestive RF revealed an increased AF detection rate with increased amount of RF (Figure 1) and the most predictive RF to be atrial high-rate episodes. Prevalence of AF increased the risk for new embolic ischemic lesions (OR 2.05 (95% 1.01–4.15)). Newly detected AF was reported in 89 patients (25.3%), 49 occurring in the ASA arm, leading to an immediate switch (from ASA to) apixaban, as required by protocol. Conclusions In contrast to the recently published NAVIGATE and RESPECT ESUS trials, patients enrolled in ATTICUS had to exhibit additional predicting factors for (but no previously diagnosed) AF. These were significantly associated with the incidence of clinical AF with AHRE as the strongest predictor. Continuous cardiac remote monitoring will help to elucidate the AF burden and risk for stroke recurrence in this cohort and the effects of early oral anticoagulation with apixaban compared to antiplatelet therapy with ASA on the incidence of stroke recurrence.

Abstract 15223: Clinical and Economic Impact of Patient Loss-to-Follow-Up After Short-Term Cardiac Monitor Usage in Cryptogenic Stroke

Introduction: Short-term cardiac monitors (STMs) are increasingly used in the work-up of cryptogenic stroke patients before proceeding to long-term continuous monitoring for atrial fibrillation (AF) with insertable cardiac monitors (ICM). However, the rate of ICM placement after STM is only 4-5% based on large real-world studies. The impact of patient fall-out after STM on clinical/economic outcomes is unknown. Research Question: The objective of this analysis was to project the risk of additional ischemic strokes and stroke-related costs with varying rates of patient loss to follow-up (LTFU) after 48-hour, 14-day or 30-day monitors, compared to an approach of continuous ICM monitoring post-stroke. Methods: A previously published Markov model based on the CRYSTAL-AF trial was utilized to project lifetime ischemic strokes after various monitoring strategies, from a US payer perspective. Patient characteristics and AF detection rates were based on CRYSTAL-AF: diagnostic yield with the initial STMs were 0.8% for 48-hr, 3.1% for 14-day and 6.8% for 30-day monitors. AF detection resulted in a change from aspirin to DOAC, with subsequent risks of ischemic strokes and associated costs (including acute + post-acute care) modeled based on published literature. Results: Increasing rates of patient LTFU after STM were associated with higher projected additional secondary strokes compared to an immediate ICM approach, across all 3 STM types (figure). In the scenario based on real-world data (95% LTFU), a range of 62-68 additional strokes are projected per 1,000 patients, with associated stroke costs of $4,928-$5,449/patient when averaged across the population. Conclusions: Loss of patient follow-up after STM in real-world CS patients is projected to lead to substantial secondary stroke burden due to undetected AF, compared to continuous monitoring with ICM. Future work could focus on optimizing stroke pathways to ensure timely and continued access to monitoring.

Abstract 15518: What Monitoring Duration is Needed to Rule Out High Atrial Fibrillation Burden?

Introduction: Atrial fibrillation (AF) burden contributes to stroke risk. AF detection rates increase with monitoring duration, but the relationship between time to the first AF episode and AF burden has not been described. We aimed to identify AF free monitoring durations after which a given AF burden can be ruled out. Methods: We included all subjects without permanent AF (n=13,106, median age 65 years (IQR 51-74 years), 40.1% male) monitored for ≥14 days in 2021 in the USA with PocketECG (MEDICALgorithmics), a full disclosure mobile cardiac telemetry device. We graphed 14-day AF burden (% time in AF/total time) by time in days before detection of prespecified AF durations (&lt;30s (micro-AF), ≥30s-6 minutes, ≥6 minutes-1 hour and ≥1 hour in mutually exclusive strata) and calculated the 95th percentile of 14-day AF burden by time to first AF episode of different durations. Confidence intervals were estimated using bootstrapping with 1000 replications. Results: There were 5,605 patients with micro-AF episodes, 1,788 patients with 30s-6min AF episodes, 748 patients with 6 min-1 hour AF episodes and 227 patients with ≥1 hour AF episodes (Fig 1 a-d). The overall AF burden was higher in subjects with longer episodes, but decreased by time to first episode for all episode durations, Figure 1e-h. After 3 days of monitoring the 95th percentile for overall AF burden was 0.03% (95%CI 0.02-0.03%) in patients without micro-AF, 0.1% (95%CI 0.08-0.11% in patients without ≥30s AF, 0.4% (95%CI 0.3-0.4%) without ≥6-minute AF episodes, and 1.5% (95%CI 1.2-1.8%) without ≥1 hour episodes of AF. Conclusions: The probability of a high AF burden decreases as AF-free monitoring time increases, and AF free monitoring time can be used to inform the need for longer monitoring. When no AF episodes lasting ≥1 hour have been detected after 3 days of monitoring the probability of an AF burden &gt;2% can be effectively ruled out.

Atrial fibrillation detected with outpatient cardiac rhythm monitoring in patients with ischemic stroke or TIA of undetermined cause

ObjectivesGuidelines advise cardiac rhythm monitoring for 3 up to 30 days for detecting atrial fibrillation (AF) in patients with ischemic stroke of undetermined cause. However, the optimal monitoring duration is unknown. We aimed to determine the AF detection rate during 7-day outpatient cardiac rhythm monitoring in this patient group. MethodsParticipants from a large tertiary hospital in a prospective observational study (ATTEST) underwent outpatient cardiac rhythm monitoring after a negative standard diagnostic evaluation (i.e., 12-lead electrocardiogram and in-hospital telemetry). Primary outcome was the rate of newly detected AF. ResultsWe examined 373 patients [age: 67.8±11.6 years; women: 166(44.5%); stroke: 278(74.5%)]. Median monitoring duration was 7 days (Inter Quartile Range (IQR) 7-7), performed after median of 36 days (IQR 27-47). AF was newly detected in 17(4.6%) patients, 5.4% of patients with ischemic stroke and 2.1% of patients with TIA. 53% of AF was detected on day-1, after day-3 73% of new AF was found. First AF episodes were detected up to day-7. Diabetes and increasing age were independent predictors of new AF. ConclusionAfter ischemic stroke or TIA of undetermined cause, 7-day outpatient cardiac rhythm monitoring detected new AF in 4.6%. Patients with AF had significantly more cardiovascular risk factors. Although about 50% of first AF episodes occurred during the first day of monitoring, new AF was detected up to day-7, implying that the recommended minimum of 3 days cardiac rhythm monitoring after ischemic stroke of undetermined cause is insufficient. Subsequent long-term rhythm monitoring should be considered in selected patients.

Comparison of the 11-Day Adhesive ECG Patch Monitor and 24-h Holter Tests to Assess the Response to Antiarrhythmic Drug Therapy in Paroxysmal Atrial Fibrillation.

Accurate assessment of the response to the antiarrhythmic drug (AAD) in atrial fibrillation (AF) is crucial to achieve adequate rhythm control. We evaluated the effectiveness of extended cardiac monitoring using an adhesive ECG patch in the detection of drug-refractory paroxysmal AF. Patients diagnosed with paroxysmal AF and receiving AAD therapy were enrolled. The subjects simultaneously underwent 11-day adhesive ECG patch monitoring and a 24-h Holter test. The primary study outcome was a detection rate of drug-refractory AF or atrial tachycardia (AT) lasting ≥30 s. A total of 59 patients were enrolled and completed the study examinations. AF or AT was detected in 28 (47.5%) patients by an 11-day ECG patch monitor and in 8 (13.6%) patients by a 24-h Holter test (p < 0.001). The 11-day ECG patch monitor identified an additional 20 patients (33.8%) with drug-refractory AF not detected by the 24-h Holter, and as a result, the treatment plan was changed in 11 patients (10 catheter ablations, one medication change). In conclusion, extended cardiac rhythm monitoring using an adhesive ECG patch in patients with paroxysmal AF under AAD therapy led to over a threefold higher detection of drug-refractory AF episodes, compared to the 24-h Holter test.

Detection of atrial fibrillation using an implantable loop recorder in patients with previous cryptogenic stroke: the SPIDER-AF registry (Stroke Prevention by Increasing DEtection Rates of Atrial Fibrillation).

The use of implantable loop recorder (ILR) to detect atrial fibrillation (AF) in patients with a history of cryptogenic stroke (CS) has seldom been investigated in "real-world" settings. This study aimed to present the results of the Stroke Prevention by Increasing DEtection Rates of Atrial Fibrillation (SPIDER-AF) registry. SPIDER is a multicentric, observational registry, including 35 facilities all over Germany. It enrolled outpatients without AF history and with CS before ILR implantation. We included 500 patients (mean age 63.1 ± 12.7years), 304 (60.8%) were males, with previous stroke (72.6%) and TIA (27.4%). After inclusion, all were followed for at least 12months. AF was detected in 133(26.8%), 25.3% of patients with previous stroke and 29.9% with TIA (p = 0.30). AF was detected after a median of 121.5days (IQR 40.5-223.0). AF was primarily paroxysmal (95.7% after stroke, 100% after TIA). In 19.5% (n = 26) anticoagulation was not administered after AF detection. Mean CHA2DS2-VASc score (OR 1.22; CI 1.01-1.49; p = 0.037) and age > 70years (OR 0.41; CI 0.19-0.88; p = 0.0020) correlated with AF. Repeat cerebrovascular events at follow-up (28; 5.6%) correlated with AF (OR = 2.17; CI 1.00-4.72; p = 0.049). AF (p = 0.91) and recurrent events (p = 0.43) occurred similarly in females and males. In the context of cryptogenic strokes ILRs are a valuable tool for early detection of AF. In a real-world scenario, the anticoagulation therapy remains inadequate despite diagnosed AF in a relevant subset of patients requiring optimization of patient management.

Regular pulse checks for patients with non-cardioembolic stroke in rehabilitation hospitals to improve recognition and detection of atrial fibrillation (the ESCORT study): protocol for a prospective multicenter observational study.

Cryptogenic stroke (CS) are heterogeneous in origin; however, most CS are embolic mechanism. Paroxysmal atrial fibrillation (AF) is suspected to be a major type of CS that leads to severe cerebral infarction without anticoagulant use. Therefore, the identification of AF is vital in patients with CS. However, patients are often unaware of AF because they have no symptoms, and AF may not be detected on an electrocardiogram (ECG) or Holter ECG on admission. After patients with stroke are treated in the acute phase, they are promptly transferred to a rehabilitation hospital for functional recovery. Once the patient is transferred to a hospital, a few attempts are made to detect AF. In addition, rehabilitation therapists are considered to have insufficient awareness of the possibility of undiagnosed AF. This study aimed to increase the understanding of the importance of AF detection in patients with ischemic stroke among therapists in rehabilitation hospitals and to investigate whether regular pulse screening can aid in the detection of AF. If AF was detected, we determined the rate and timing of AF detection and identified the patient characteristics. This multicenter prospective observational study aimed to detect AF in patients with non-cardiac stroke at rehabilitation hospitals. Therapists performed pulse checks before, during, and after rehabilitation. If arrhythmia or tachycardia was detected, an ECG was performed, and the physician checked for AF. If the patient complained of chest symptoms, electrocardiography (ECG) was performed to check for AF. We investigated the characteristics, laboratory data, cognitive status, complications, such as stroke recurrence, and functional outcomes of patients with AF. The study is in the enrollment phase. Recruitment began in September 2022 and will end in August 2023. Patients have provided written informed consent. The main results have been submitted for publication in your journal. The findings of this study will help identify patients with AF in rehabilitation hospitals and improve awareness among therapists.

Detection rates of asymptomatic carotid artery stenosis and atrial fibrillation by selective screening of patients without cardiovascular disease

BackgroundIndividuals with significant asymptomatic carotid artery stenosis (ACAS) and atrial fibrillation (AF) could benefit from specific interventions to prevent heart attack and stroke, but are often clinically ‘silent’. We aimed to determine detection rate of ACAS and AF by screening, targeting a population at increased cardiovascular risk. MethodsData on adults who attended voluntary and self-funded commercial screening clinics in the United States or the United Kingdom between 2008 and 2013 were used. The Atherosclerotic Cardiovascular Disease (ASCVD) risk equation was applied to each participants and detection rates of targeted screening for ≥50% ACAS and AF to those at highest risk of CVD was assessed. ResultsAmong 0.4 million individuals between 40 and 80 years, without CVD, 6191 (1.6%) had ACAS and 1026 (0.3%) had AF. Selective screening of participants with a predicted 10-year CVD risk of ≥20% identified 40% of ACAS cases, a prevalence of 3.7%, leading to a number needed to screen (NNS) of 27, as well as 39% of AF cases, a prevalence of 0.6%, with a NNS of 170. Selective screening of those with a predicted 10-year CVD risk of ≥15% identified 54% of ACAS cases, a prevalence of 3.3%, and an NNS of 31, as well as 51% of AF cases, a prevalence of 0.5%, with an NNS of 195. ConclusionsSelective screening for ACAS and AF implemented in ASCVD risk assessment greatly reduces the NNS when compared with population-level screening with detection rates of ACAS and AF substantially greater in people at higher predicted CVD risk.

The Report of Community-Based and Government-Endorsed Screening Program of Atrial Fibrillation in Taiwan.

Although international guidelines recommended opportunistic screening for atrial fibrillation (AF), the community-based AF screening program incorporated into the government-endorsed health care system is rarely reported in Asian countries. We aimed to test the feasibility of adding AF screening into the preexistent adult health check program and report the AF detection rate and percentages of OAC prescriptions before and after AF screening with the involvement of public health care systems. We performed this program in three counties (Chiayi county, Keelung City, and Yilan county) in Taiwan which have their own official preexistent adult health check programs conducted by public health bureaus for years. However, electrocardiography (ECG) was not included in these programs before. We cooperated with the public health bureaus of the three counties and performed single-lead 30-second ECG recording for every participant. From January to December 2020, AF screening was performed in 199 sessions with 23,572 participants. AF was detected in 278 subjects with a detection rate of 1.19% (age ≥65 years: 2.39%; ≥75 years: 3.73%). The mean CHA2DS2-VASc score of these 278 subjects was 2.36, with 91% of them had a score ≥1 (males) or ≥2 (females). The number needed to screen was 42 and 27 for subjects aged ≥65 and ≥75 years, respectively. The prescription rate of OACs significantly increased from 11.4 to 60.6% in Chiayi county and from 15.8 to 50.0% in Keelung City after screening (both p-values <0.001). This community-based and government-endorsed AF screening project in Taiwan demonstrated that incorporation of AF screening into the preexistent adult health check programs through co-operations with the government was feasible. Actions to detect AF, good education, and well-organized transferring plan after AF being detected with the involvement of public health care systems could result in a substantial increase in the prescription rate of OACs.

The Role of Implantable Loop Recorder in Patients with Cryptogenic Stroke

Objective: The objective of this study was to provide data on implantable loop recorder (ILR)-based atrial fibrillation (AF) rates, recurrent stroke rates, and predictors of AF in patients with cryptogenic stroke (CS) after 1, 6, 12, 24, and 36 months of follow-up. Methods: We searched MEDLINE/PubMed, Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, and reference lists of retrieved reports, which were published by April 30, 2023, which was the date of our last search. We utilized random-effects meta-analysis for detection rates, and meta-regression analysis, t-test (for normally distributed variables), and Mann-Whitney (for skewed variables) for predictor factors. Results: Thirteen studies were analyzed, which included data from 3,377 patients with CS or embolic stroke of undetermined source. The ILR-based AF rates in patients with CS were 4.73% (95% confidence interval [CI] 3.91–5.71) at 1 month, 13.45% (95% CI 12.19–14.81) at 6 months, 17.5% (95% CI 16.25–18.82) at 12 months, 20.69% (95% CI 19–22.49) at 24 months, and 25.98% (95% CI 23.21–28.58) at 36 months. Age and CHA2DS2-VASc score were positively associated with AF detection. Specifically, the mean difference of age and CHA2DS2-VASc score in the group with AF versus the group without AF was 7.47 (95% CI 4.58–10.36, P &lt; 0.001) and 0.75 (95% CI 0.22–1.28, P = 0.01), respectively. Finally, AF detection was positively associated with recurrent strokes with an estimated risk ratio of 1.27 (95% CI 0.69–2.31). Conclusions: There is a correlation between AF detection rate and ILR monitoring duration. One out of eight patients was diagnosed with AF after 6 months of follow-up and about one quarter after 3 years. Our results demonstrate the critical use of ILRs, especially in older patients, and in patients with high CHA2DS2-VASc scores.

A Systematic Review and Meta-analysis of Atrial Fibrillation Detection Rates in Cancer Survivors

A Systematic Review and Meta-analysis of Atrial Fibrillation Detection Rates in Cancer Survivors

Detection of atrial fibrillation in real world setting in patients with cryptogenic stroke and an implantable loop recorder.

Implantable loop recorders (ILR) are used to screen for atrial fibrillation (AF) in patients with cryptogenic stroke (CS). However, there is limited real-world data regarding the long-term rate of AF detection using ILR and management consequences in patients with CS. The objective is to assess the rate of AF detection in patients with CS in a real-world study over 36 months of follow-up and its consequences on stroke prevention. This retrospective study included patients with an ILR placed for CS at Baylor College of Medicine and Baylor St. Luke's Medical Center between January 2014 and July 2021. The primary outcome was AF detection in patients with ILR. The secondary outcome was the rate of subsequent strokes after ILR placement in patients with or without diagnosed AF. The AF detection rate in our cohort was compared to the rate in CRYSTAL-AF Trial at 36-month follow-up. The impact of AF detection on clinical management was examined. We identified 225 patients. 51.1% were women and 38.2% African American. Among 85 patients with ILR labeled AF, 43 patients had true AF, and 42 had incorrectly labeled AF (48.3% false positive). The estimated AF detection rate at 36 months follow-up was 28.6% (95% CI, 26.6%-30.6%). 58.1% of patients with AF were initiated on oral anticoagulation, 80.0% of whom were started on a direct oral anticoagulant. 13.8% of patients had recurrent strokes after ILR implantation; 4 of whom were diagnosed with AF. Compared to CRYSTAL-AF, the AF detection rate in our cohort is similar, but this cohort includes a higher proportion of female and African American patients. Most patients with recurrent strokes after ILR implant did not have AF during 36 months of monitoring.