Prolonged Monitoring Research Articles

Experience and insights from a prolonged electrocardiographic monitorization with a wearable system after an embolic stroke of unknown source.

Embolic cerebrovascular events that remain of unknown etiology after a thorough diagnostic evaluation, are known as Embolic Strokes of Undetermined Source (ESUS). Subclinical atrial fibrillation (AF) represents a significant underlying cause of ESUS. Our aims were to examine the overall diagnostic yield of a prolonged cardiac monitoring wearable system (PCMw) after an ESUS to detect AF and factors associated with it, including the time frame from the ESUS event to PCMw initiation. Additionally, to evaluate the frequency of unexpected arrhythmic events (UAE) and their prognostic implications. We retrospectively analyzed 200 ECG recordings (3-leads, 30days duration) by means of a PCMw in patients with an ESUS to detect AF lasting longer than 30s, between 2017 and 2021. UAE were defined as arrhythmia events that were not correlated to the main reason of prolonged cardiac monitoring. AF was detected in 21 patients (10.5%). Patients with AF had more left atrial enlargement (OR=4.22 [1.59-6.85]; p=.01) and atrial arrythmias in the initial 24-h Holter during hospitalization (OR=5.73 [2.03-16.49]; p=.001). The detection of AF was significatively higher if the PCMw was worn within the first 30days after the ESUS compared to beyond 30days (17% vs. 10.3%; p=.002). Fifty three patients (26.5%) had UAE during PCMw. In six of them these findings led to targeted treatment. PCMw represents a feasible non-invasive device that could reliably detect subclinical AF episodes after an ESUS. Diagnostic yield was significatively higher when used within the first 30days after the event, especially in selected patients. UAE were common, but did not impact prognosis.

Two-year evolution of quality of life following radiotherapy and/or chemotherapy in patients with head and neck cancer

ObjectiveThis study aims to elucidate the trajectory of quality of life (QoL) over a two-year period after radiotherapy and/or chemotherapy for head and neck cancer (HNC), addressing the gap in long-term QoL information. MethodsEmploying a prospective longitudinal observational design, we tracked 58 HNC patients who underwent radiotherapy and/or chemotherapy, analyzing their QoL using Short-Form 36-Item Health Survey version 2 (SF36v2), the European Organization for Research and Treatment of Cancer quality of life (EORTC-QLQ-C30), and the European Organization for Research and Treatment of Cancer quality of life head and neck-35 (EORTC-QLQ-H&N35) questionnaires for two years post-discharge. The data underwent repeated measures analysis of variance. ResultsOver the two-year follow-up, 10 patients (17.2%) succumbed, and 8 (13.8%) dropped out. SF36v2 physical and role-social component summary scores declined during treatment, requiring 1–2 years for recovery. The mental component summary score remained stable. EORTC-QLQ-30 revealed global health status recovery within one year post-discharge. EORTC-QLQ-H&N35 items like “swallowing,” “senses problems,” “trouble with social eating,” “dry mouth,” “sticky saliva,” “coughing,” and “felt ill” worsened pre-discharge. “Trouble with social contact” improved within a year, while “pain,” “swallowing,” “senses problems,” “trouble with social eating,” and “coughing” improved within two years. “Dry mouth” and “sticky saliva” persisted throughout the two-year follow-up, common symptoms of HNC and treatment side effects. ConclusionsRecovery of specific QoL aspects in HNC patients treated with radiotherapy and/or chemotherapy may require up to two years. Prolonged monitoring and management of oral symptoms could enhance QoL. Future research should extend follow-up beyond two years for comprehensive interventions enhancing patient QoL.

Utilization of Regional Anesthesia in the Electrophysiology Lab: A Narrative Review.

The electrophysiology lab is an important source of growth of anesthetic volume as the indications and evidence for catheter ablations and various cardiac implantable electronic devices improve. Paired with this increase in volume is an increasing number of patients with substantial comorbid conditions presenting for their EP procedures. For these patients, the interaction between their comorbidities and traditional anesthesia practices may create the risk of hemodynamic instability, cardiovascular or respiratory complications, and potential need for prolonged post-operative monitoring negatively impacting length of hospital stay. Regional anesthetic techniques, including pectoralis, serratus, and erector spinae plane blocks, offer options for both regional analgesia and surgical anesthesia for a variety of EP procedures. Existing case reports and extrapolations from other areas support these techniques as viable, safe, and effective components of an anesthetic plan. In this article, we will review the development and challenges of various EP procedures and how different regional anesthetic techniques can function as a component of the anesthesia plan.

Subclinical Atrial Fibrillation on Prolonged ECG Holter Monitoring: Results from the Multicenter Real-World SAFARI (Silent Atrial Fibrillation ANCE-Sicily Research Initiative) Study.

The detection of subclinical/silent atrial fibrillation (SAF) in the general population is of the utmost importance, given its potential adverse consequences. Incident AF has been observed in 30% to 70% of patients with implanted devices, but its prevalence may indeed be lower in the general population. The prospective, multicentric, observational Silent Atrial Fibrillation ANCE Research Initiative (SAFARI) study aimed at assessing the SAF prevalence in a real-world outpatient setting by the means of a small, wearable, prolonged ECG Holter monitoring (>5 days) device (CGM HI 3-Lead ECG; CGM TELEMEDICINE, Piacenza, Italy). Patients ≥ 55 years of age at risk for AF were screened according to the inclusion criteria to undergo prolonged 3-lead ECG Holter monitoring. SAF episodes were classified as follows: Class A, <30 s; Class B, 30 to 299 s; and Class C, ≥300 s. In total, 119 patients were enrolled (64 men; median age 71 (IQR 55-85) years). At a median of 13.5 (IQR 5-21) days of monitoring, SAF episodes were found in 19 patients (16%). A total of 10,552 arrhythmic episodes were registered, 6901 in Class A (n = 7 patients), 2927 in Class B (n = 3), and 724 in Class C (n = 9), (Class A vs. B and C, p < 0.001). This latter group had multiple (all-class) episodes, and two patients had >1000 episodes. There were no clinical, echocardiographic, or laboratory findings able to discriminate patients with SAF from those in sinus rhythm in univariate and multivariable analyses; of note is that the Class C patients showed a higher diastolic blood pressure, resting heart rate, and indexed LA volume. Over a median of 13 days of Holter monitoring, the SAFARI study confirmed the usefulness of small wearable devices in detecting SAF episodes in real-world outpatients at risk for, but with no prior history of, AF.

An autonomous wearable biosensor powered by a perovskite solar cell.

Wearable sweat sensors can potentially be used to continuously and non-invasively monitor physicochemical biomarkers that contain information related to disease diagnostics and fitness tracking. However, the development of such autonomous sensors faces a number of challenges including achieving steady sweat extraction for continuous and prolonged monitoring, and addressing the high power demands of multifunctional and complex analysis. Here we report an autonomous wearable biosensor that is powered by a perovskite solar cell and can provide continuous and non-invasive metabolic monitoring. The device uses a flexible quasi-two-dimensional perovskite solar cell module that provides ample power under outdoor and indoor illumination conditions (power conversion efficiency exceeding 31% under indoor light illumination). We show that the wearable device can continuously collect multimodal physicochemical data - glucose, pH, sodium ions, sweat rate, and skin temperature - across indoor and outdoor physical activities for over 12 hours.

Atrial fibrillation in embolic stroke of undetermined source: role of advanced imaging of left atrial function.

Atrial fibrillation (AF) is detected in over 30% of patients following an embolic stroke of undetermined source (ESUS) when monitored with an implantable loop recorder (ILR). Identifying AF in ESUS survivors has significant therapeutic implications, and AF risk is essential to guide screening with long-term monitoring. The present study aimed to establish the role of left atrial (LA) function in subsequent AF identification and develop a risk model for AF in ESUS. We conducted a single-centre retrospective case-control study including all patients with ESUS referred to our institution for ILR implantation from December 2009 to September 2019. We recorded clinical variables at baseline and analysed transthoracic echocardiograms in sinus rhythm. Univariate and multivariable analyses were performed to inform variables associated with AF. Lasso regression analysis was used to develop a risk prediction model for AF. The risk model was internally validated using bootstrapping. Three hundred and twenty-three patients with ESUS underwent ILR implantation. In the ESUS population, 293 had a stroke, whereas 30 had suffered a transient ischaemic attack as adjudicated by a senior stroke physician. Atrial fibrillation of any duration was detected in 47.1%. The mean follow-up was 710 days. Following lasso regression with backwards elimination, we combined increasing lateral PA (the time interval from the beginning of the P wave on the surface electrocardiogram to the beginning of the A' wave on pulsed wave tissue Doppler of the lateral mitral annulus) [odds ratio (OR) 1.011], increasing Age (OR 1.035), higher Diastolic blood pressure (OR 1.027), and abnormal LA reservoir Strain (OR 0.973) into a new PADS score. The probability of identifying AF can be estimated using the formula. Model discrimination was good [area under the curve (AUC) 0.72]. The PADS score was internally validated using bootstrapping with 1000 samples of 150 patients showing consistent results with an AUC of 0.73. The novel PADS score can identify the risk of AF on prolonged monitoring with ILR following ESUS and should be considered a dedicated risk stratification tool for decision-making regarding the screening strategy for AF in stroke.

Intensive heart rhythm monitoring to decrease ischemic stroke and systemic embolism—the Find-AF 2 study—rationale and design

Atrial fibrillation (AF) is one of the most frequent causes of stroke. Several randomized trials have shown that prolonged monitoring increases the detection of AF, but the effect on reducing recurrent cardioembolism, ie, ischemic stroke and systemic embolism, remains unknown. We aim to evaluate whether a risk-adapted, intensified heart rhythm monitoring with consequent guideline conform treatment, which implies initiation of oral anticoagulation (OAC), leads to a reduction of recurrent cardioembolism. Find-AF 2 is a randomized, controlled, open-label parallel multicenter trial with blinded endpoint assessment. 5,200 patients ≥ 60 years of age with symptomatic ischemic stroke within the last 30 days and without known AF will be included at 52 study centers with a specialized stroke unit in Germany. Patients without AF in an additional 24-hour Holter ECG after the qualifying event will be randomized in a 1:1 fashion to either enhanced, prolonged and intensified ECG-monitoring (intervention arm) or standard of care monitoring (control arm). In the intervention arm, patients with a high risk of underlying AF will receive continuous rhythm monitoring using an implantable cardiac monitor (ICM) whereas those without high risk of underlying AF will receive repeated 7-day Holter ECGs. The duration of rhythm monitoring within the control arm is up to the discretion of the participating centers and is allowed for up to 7 days. Patients will be followed for at least 24 months. The primary efficacy endpoint is the time until recurrent ischemic stroke or systemic embolism occur. The Find-AF 2 trial aims to demonstrate that enhanced, prolonged and intensified rhythm monitoring results in a more effective prevention of recurrent ischemic stroke and systemic embolism compared to usual care.

Differences in Stroke Recurrence Risk Between Atrial Fibrillation Detected on ECG and 14-Day Cardiac Monitoring.

Ischemic stroke and transient ischemic attack (TIA) standard-of-care etiological investigations include an ECG and prolonged cardiac monitoring (PCM). Atrial fibrillation (AF) detected after stroke has been generally considered a single entity, regardless of how it is diagnosed. We hypothesized that ECG-detected AF is associated with a higher risk of stroke recurrence than AF detected on 14-day Holter (PCM-detected AF). We conducted a retrospective, registry-based, cohort study of consecutive patients with ischemic stroke and TIA included in the London Ontario Stroke Registry between 2018 and 2020, with ECG-detected and PCM-detected AF lasting ≥30 seconds. We quantified PCM-detected AF burden. The primary outcome was recurrent ischemic stroke, ascertained by systematically reviewing all medical records until November 2022. We applied marginal cause-specific Cox proportional hazards models adjusted for qualifying event type (ischemic stroke versus TIA), CHA₂DS₂-VASc score, anticoagulation, left ventricular ejection fraction, left atrial size, and high-sensitivity troponin T to estimate adjusted hazard ratios for recurrent ischemic stroke. We included 366 patients with ischemic stroke and TIA with AF, 218 ECG-detected, and 148 PCM-detected. Median PCM duration was 12 (interquartile range, 8.8-14.0) days. Median PCM-detected AF duration was 5.2 (interquartile range, 0.3-33.0) hours, with a burden (total AF duration/total net monitoring duration) of 2.23% (interquartile range, 0.13%-12.25%). Anticoagulation rate at the end of follow-up or at the first event was 83.1%. After a median follow-up of 17 (interquartile range, 5-34) months, recurrent ischemic strokes occurred in 16 patients with ECG-detected AF (13 on anticoagulants) and 2 with PCM-detected AF (both on anticoagulants). Recurrent ischemic stroke rates for ECG-detected and PCM-detected AF groups were 4.05 and 0.72 per 100 patient-years (adjusted hazard ratio, 5.06 [95% CI, 1.13-22.7]; P=0.034). ECG-detected AF was associated with 5-fold higher adjusted recurrent ischemic stroke risk than PCM-detected AF in a cohort of ischemic stroke and TIA with >80% anticoagulation rate.

Enhanced diagnostic workup increases pathological findings in patients with acute ischaemic stroke: results of the prospective HEBRAS study

BackgroundStroke aetiology remains cryptogenic in a relevant proportion of patients with acute ischaemic stroke (AIS). We assessed whether enhanced diagnostic workup after AIS yields a higher rate of prespecified pathological...

An overview of the electrocardiographic monitoring devices in sports cardiology: Between present and future.

Athletes represent a mainly healthy population, which however could be considered at risk of major arrhythmic events, especially in case of undiagnosed cardiomyopathies. For this reason, the periodical sports medicine examination and the electrocardiography are essential tools in the cardiovascular screening, even though they do not always succeed in identifying rhythm disturbances, particularly when asymptomatic or rarely symptomatic. Prolonged cardiac monitoring often enables clinicians to stratify the arrhythmic risk and reach the diagnosis. The technological progress of the last decades has produced an always-increasing number of heart rhythm monitoring devices, starting from the 24-hourelectrocardiogram Holtermonitoring and ending with the wide world of wearable devices. In the literature, the extreme utility of this equipment in the patients affected by cardiovascular diseases and in the general population is well established. On the contrary, athletes-based randomized trials or large-scale epidemiological studies targeting the frequency of cardiac symptoms and the use of cardiac monitoring are missing, while an ever-growing number of case series and small observational studies are flourishing in recent years. The present review showcases the available electrocardiographic monitoring options, principally in the medical setting, listing their characteristics, their indications, their supporting evidence, and their general pros and cons. The ultimate goal of this review is guiding physicians through the wide variety of heart rhythm monitoring options in the specific subfield of sports cardiology, when an arrhythmia is suspected in an athlete, to tailor the diagnostic process and favor the best diagnostic accuracy.

The left atrial morphologic and functional parameters as predictors of paroxysmal atrial fibrillation in patients after ischemic stroke

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiogenic source of embolism is the most common cause of non-lacunar ischemic stroke (IS). Identifying the patients with undiagnosed paroxysmal atrial fibrillation (PAF) may reduce the risk of recurrent cardiogenic strokes. Reliable predictors of PAF seems to be crucial for selection the patients to prolonged ECG monitoring after IS. Purpose To assess the feasibility of echocardiography in selecting the patients with highest risk of PAF. Methods We present the preliminary data of prospective cohort study of patients after IS or transient ischemic attack of unknown aetiology and possible cardiogenic origin. The examined group comprises of 40 consecutive patients without history of AF, capable to perform ECG recording. All patients included in the study had transthoracic echocardiography (TTE) prior the monitoring period. An offline analysis including left atrial functional and morphologic assessment was performed. Every patient enrolled in the study was equipped for 2 weeks with a mobile, on demand 1-minute single lead ECG recorder and was asked for at least two exams per day. After two weeks all recorded ECGs were checked for AF occurrence. The level of statistical significance was set at p&amp;lt;0.05. Results From 40 patients (aged 64,5 yrs in average) included in the study 45% were males; (n=18). 15% (n=6) of patients were diagnosed with PAF during ECG monitoring and comprised PAF subgroup, the rest of patients formed non PAF subgroup (nPAF). Mean number of ECG records was 56,5 per patient, during the monitoring period. There were no significant differences between PAF/nPAF in age, past medical history, and left ventricular (LV) size or systolic function. Patients from PAF group have statistically significant higher values of left atrial (LA) area and volume see table 1. PAF group has significantly lower (in absolute values) left atrial contraction strain – (LASct). There were no differences in conduit and reservoir LA (LASr) strains nor in LA ejection fraction. The highest PAF diagnosis efficacy according to area under the curve (AUC) of ROC curves was noted for parameters of: LA size: LA atrium volume index (LAVI) in 4 chamber view (AUC=0,82) and LA area index (0,81) LA contraction function: LASct (Avg) (AUC =0,80) LV diastolic function: E/E’ (0,81) For the threshold of 100% sensitivity the highest specificity was found for LA volume before active atrial contraction in 4 chamber view with cut-off value of &amp;gt;=37,6 ml (specificity 64,7%) (Figure 1.) and LASct (Avg) with cut-off value &amp;lt;=17% in absolute values (specificity 47,1%). Conclusions Both functional and morphologic parameters of LA can predict PAF diagnosis during ECG monitoring after IS. TTE after IS can be used to select patients who would benefit the most from prolonged ECG monitoring. High PAF detectability (100% sensitivity) with approximately 1/2 negative results of ECG monitoring can be achieved by both LA volumetric (LAV preA) and strain (LASct) analysis.

World Stroke Organization Brain & hEart globAl iniTiative Program

Introduction: The World Stroke Organization (WSO) Brain & Heart Task Force developed the Brain & hEart globAl iniTiative (BEAT), a pilot feasibility implementation program to establish clinical collaborations between cardiologists and stroke physicians who work at large healthcare facilities. Methods: The WSO BEAT pilot project focused on atrial fibrillation (AF) and patent foramen ovale (PFO) detection and management, and poststroke cardiovascular complications known as the stroke-heart syndrome. The program included 10 sites from 8 countries: Brazil, China, Egypt, Germany, Japan, Mexico, Romania, and the USA The primary composite feasibility outcome was the achievement of the following 3 implementation metrics (1) developing site-specific clinical pathways for the diagnosis and management of AF, PFO, and the stroke-heart syndrome; (2) establishing regular Neurocardiology rounds (e.g., monthly); and (3) incorporating a cardiologist to the stroke team. The secondary objectives were (1) to identify implementation challenges to guide a larger program and (2) to describe qualitative improvements. Results: The WSO BEAT pilot feasibility program achieved the prespecified primary composite outcome in 9 of 10 (90%) sites. The most common challenges were the limited access to specific medications (e.g., direct oral anticoagulants) and diagnostic (e.g., prolonged cardiac monitoring) or therapeutic (e.g., PFO closure devices) technologies. The most relevant qualitative improvement was the achievement of a more homogeneous diagnostic and therapeutic approach. Conclusion: The WSO BEAT pilot program suggests that developing neurocardiology collaborations is feasible. The long-term sustainability of the WSO BEAT program and its impact on quality of stroke care and clinical outcomes needs to be tested in a larger and longer duration program.

Long-term outcomes of chronic immune-related adverse events from adjuvant anti-PD-1 therapy for high-risk resected melanoma.

9591 Background: Adjuvant anti-PD1 improves relapse-free survival in high-risk, resected melanoma, but can lead to irAEs, which become chronic in up to 41% of patients (Patrinely et al, JAMA Onc 2021). Given the expanding use of anti-PD-1 in earlier settings in many tumors, it is imperative to assess their long-term effects. We aimed to determine the incidence, characteristics, and long-term outcomes, including resolution vs persistence, of chronic irAEs from adjuvant anti-PD1. Methods: We retrospectively analyzed patients (pts) treated with adjuvant anti-PD1 for resected stage III-IV melanoma from 2015-2022 from 6 institutions; all pts had at least 18 month follow up post-anti-PD1 discontinuation. Demographics, disease characteristics, treatment and recurrence details, and outcomes were collected. Type, grade, duration, treatment, and resolution of acute (onset during treatment) and chronic irAEs (defined as those extending 6+ months after treatment cessation) were characterized. Results: Among 318 pts, 226 (64%) developed acute irAEs arising during treatment, including 44 (20%) with grade 3-5 irAEs. Chronic irAEs developed in 147 (46%) pts, of which 74 (50%) were grade 2+, 6 (4%) were grade 3-5, and 100 (68%) were symptomatic. With long-term follow-up (median 35 months), 52 (35%) pts experienced resolution of chronic irAEs while 95 (30% of the full cohort) had persistent chronic irAEs at last follow-up. Among these 95 pts with persistent chronic irAEs, 43 (45%) were grade 2+, 42 (44%) were symptomatic, 24 (16%) were on steroids, and 42 (29%) were on other management. The most common persistent chronic irAEs were hypothyroid (n = 38), arthritis (n = 18), dermatitis (n = 9), and adrenal insufficiency (n = 8). Of 37 pts with chronic irAEs who received additional immunotherapy, 12 (32%) had a flare, 10 (27%) had no effect, and 20 (54%) had a distinct irAE. Conclusions: In this large cohort of anti-PD1 treated pts, chronic irAEs were common (46%) and frequently were persistent with long-term follow up (30%, most often hypothyroid and arthritis). Prolonged monitoring and management are needed for these long-term survivors. [Table: see text]

The use of a new ECG patch for exercise and prolonged monitoring: usability, evaluation of signal quality and utility to detect arrhythmias

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ITEA. Background Accurate detection of myocardial ischemia and arrhythmia’s during free-living exercise could play a pivotal role in optimizing screening and monitoring of individuals with underlying cardiovascular disease. Although remote electrocardiogram (ECG) solutions are emerging rapidly, these applications are generally not designed nor validated for continuous use during vigorous exercise. Purpose In this proof-of-concept study, we evaluated the usability, signal quality and arrhythmia detection of a new self-adhesive dry electrode ECG patch, the Nighthawk Vital Signs patch, during exercise and prolonged continuous ECG monitoring in individuals with chronic coronary syndrome (CCS). Methods Six consecutive CCS patients scheduled for an exercise stress test as part of routine cardiac follow-up were recruited. The traditional 12-lead exercise ECG was combined with monitoring with the 1-lead patch. Following the exercise test, the subjects continuously wore the sensor for five days. Intraclass correlation coefficients (ICC) and Wilcoxon signed-rank tests were used to assess the utility to detect arrhythmias with the patch. Signal quality for ECG recording was evaluated by using a signal quality indicator (SQI) based on the average QRS complex. Connection time and signal-to-noise ratio (SNR) were additionally calculated for prolonged ECG monitoring. Comfort and usability of the patch were evaluated by an online questionnaire. Results Six male patients with CCS (mean age 69.8 ± 6.2 years) completed the protocol. The mean time the patch was worn, was 118.3 hours (SD 5.6). The level of agreement between the patch and the 12-lead ECG was excellent for amount of premature atrial contractions (PAC’s) and premature ventricular contractions (PVC’s) during exercise stage, recovery stage and total test duration (ICC = 0.998, 0.998, 1.000, 1.000, 0.998, 1.000). There were no significant differences in the total amount of PAC’s and PVC’s detected with both methods during the exercise test (p = 0.785 and 0.180, respectively). One episode of atrial fibrillation was detected identically on both recorded ECG’s. Signal quality based on average QRS SQI during exercise did decrease slightly during (sub)maximal effort. Total connection time during recording was above 88% in all subjects and the SNR was above the target limit of 18dB. There were no reports on skin irritation, erythema or pain. Conclusion The Nighthawk Vital Signs ECG patch based on self-adhesive dry electrodes technology can be used for accurate arrhythmia detection during vigorous exercise. The sensor is also usable for prolonged ECG monitoring in free-living conditions and can therefore be of potential use in cardiac rehabilitation and telemonitoring for prevention of exercise-related cardiovascular events. However, more research is needed in order to analyze the signal quality over time together with a larger-scale validation study focusing on both arrhythmia and ischemia detection.

Rigorous and long-term cardiac monitoring strategy in cryptogenic stroke or TIA patients in a tertiary care centre results in a two-fold increase in AF detection

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Special Research Fund (Bijzonder Onderzoeksfonds, BOF) Hasselt University. This study is part of Limburg Clinical Research Center, supported by the foundation Limburg Sterk Merk, province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital. Background Atrial fibrillation (AF) is a major cause of ischaemic stroke. Oral anticoagulation is recommended in stroke survivors with AF to prevent recurrence. Prolonged ECG monitoring using insertable cardiac monitors (ICMs) has been shown to increase the detection rate of AF compared to standard 24-hour ECG monitoring in cryptogenic stroke patients. However, prolonged ambulatory ECG monitoring is underutilized, likely contributing to an underdiagnosis of AF and missed anticoagulation treatment opportunities for secondary stroke prevention. Purpose This study aims to evaluate how our evolving cardiac monitoring strategy affected AF detection rates one year after cryptogenic ischaemic stroke or transient ischaemic attack (TIA) in a tertiary care centre. Methods We retrospectively identified all consecutive cryptogenic stroke or TIA patients admitted to our centre between 1/01/2017 – 1/01/2022. Patients with a pacemaker or implantable cardioverter-defibrillator were excluded from the analysis. Data were collected from the electronic medical record. Available cardiac monitoring modalities included 24-hour Holter monitoring, 7-day Holter monitoring, and insertable cardiac monitors (ICM). After October 2020 (i.e., period 2), the latter became part of our routine diagnostic workup for AF detection in case extended (7-day) Holter monitoring was negative. Results All 691 cryptogenic stroke or TIA patients admitted to our hospital during the inclusion period were considered. These were elderly patients (69.7 ± 13.2 years) with a CHA2DS2-VASc score of 3 [2 - 5]. Figure 1 shows evolving trends in the use of the different cardiac monitoring tools before and after October 2020. In particular, the use of 7-day Holter monitoring and long-term continuous monitoring with ICM increased after implementing our new diagnostic protocol compared to 24-hour Holter monitoring (p&amp;lt;.001). ICMs were inserted 95 [66 – 145] days after index stroke or TIA. The new diagnostic protocol detected more AF one year after the index stroke or TIA (3.7% vs. 10.1%, p&amp;lt;.001, Figure 2). In 95.6% of patients with AF detected within one year, oral anticoagulation was initiated. Future research should determine whether adopting a strategy of routine ICM following cryptogenic stroke and, thus, more appropriate anticoagulant therapy may improve clinical outcome in these patients. Conclusions The increased use of prolonged cardiac monitoring in cryptogenic stroke or TIA patients resulted in a two-fold increase in AF detection one year after stroke. Therefore, our results underscore the need to implement guideline-recommended prolonged rhythm monitoring using ICMs in addition to short-term ECG monitoring to ensure adequate secondary stroke prevention.

Prolonged electrocardiographic monitorization with a wearable system after an embolic stroke of undetermined source

Abstract Funding Acknowledgements Type of funding sources: None. Background Embolic cerebrovascular events that remain of unknown etiology after careful diagnostic evaluation are known as Embolic Strokes of Undetermined Source (ESUS). Subclinical atrial fibrillation (AF) is an important cause of ESUS. Purpose Our aims were to analyze the global diagnostic yield of a prolonged cardiac monitoring wearable system (PCMw) after an ESUS to detect AF and factors associated with it, including the time frame from the ESUS event to PCMw initiation. Methods We retrospectively analyzed 200 ECG recordings (3-leads, 30 days duration) by means of a PCMw in patients with an ESUS to detect AF lasting longer than 30 seconds, between 2017-2021. Results AF was detected in 21 patients (10,5 %). Patients with AF had more left atrial enlargement (OR=4,22 [1.59-6.85]; p=0.01) and atrial arrythmias in the initial 24-h Holter during hospitalization (OR=5,73 [2.03-16,49]; p=0.001). The detection of AF was significatively higher if the PCMw was worn within the first 30 days after the ESUS compared to beyond 30 days (17% vs 10,3%; p=0,002). Conclusion PCMw represents a feasible non-invasive device that could reliably detect subclinical AF episodes after an ESUS. Diagnostic yield was significatively higher when used within the first 30 days after the event, especially in selected patients.

QT prolongation-related ventricular arrhythmia associated with atrial fibrillation electrical cardioversion

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrillation (AF) is the most common arrhythmia, a leading cause of strokes, and associated with an increased mortality. Although electrical cardioversion of AF is considered a relatively safe procedure, post cardioversion QT prolongation-related ventricular arrhythmias (VA) may appear due to the combination of QT-prolonging anti-arrhythmic drugs, acute heart rate change from rapid AF into sinus bradycardia, electrolyte imbalance, etc. To date, there is still no consensus regarding the actual prevalence of this complication. Given the global tendency for early discharge during the same day of AF cardioversion, there is a crucial need to define the true prevalence of this phenomenon and the characteristics of these patients. Purpose Evaluate the prevalence of post AF cardioversion prolonged QT-related VA, and describe the characteristics of patients developing this complication. Method Single center retrospective analysis of all AF electrical cardioversions, during the last 3 years, which were followed by documented prolonged QT-related VA or sudden cardiac death (SCD) within 72 hours from cardioversion. Post cardioversion VA was detected by a computerized search of hospitalization records, 24-hour Holter recordings, and EMS strips. Results Out of 950 AF electrical cardioversions performed at our hospital during the last 3 years there were 4 cases with Torsades de Pointes (TdP) and 1 case of SCD occurring within 72 hours from cardioversion (5/950; 0.5%). All five patients were females, 3/5 with low LVEF and 4/5 on class III anti-arrhythmic drug (Amiodarone or Sotalol). Electrolyte abnormalities (including hypokalemia, hypomagnesemia, and hypocalcemia) were found in 3/5 patients and post cardioversion sinus bradycardia in 2/5 patients. Conclusion The incidence of post-AF cardioversion life threatening VA is low although non-negligible. Prolonged ECG monitoring and cautious follow-up of QTc should be recommended among patients, especially females with low LVEF, treated by class III anti-arrhythmic drugs. Post AF cardioversion same day discharge should be discouraged in these patients.

Added value of 12-lead 24-hour ambulatory ECG monitoring in the identification of a spontaneous type 1 Brugada pattern and its prognostic role. A sub-study of the BHF RASE Brugada project

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Background A spontaneous type 1 Brugada (spT1-BrS) pattern is a recognised marker of arrhythmic risk. However, its fluctuations may underestimate the risk in subjects with concealed T1-BrS at presentation. Aim To investigate the yield of repeat resting and high-lead 12-lead ECG and the additional role of 12-lead 24-hour Holter monitoring with leads V1 and V2 in standard and high precordial ECG positions (12-HPL Holter), and evaluate the prognostic role of spT1-BrS in a large, single-centre, cohort of BrS patients. Methods Three-hundred and eighty-one subjects with BrS enrolled in our Registry from 2008 to December 2021 and with at least 3 months follow-up data were included in this study. Seventy-seven had spT1-BrS pattern at presentation (Group 1), and 304 did not (Group 2). All received lifestyle recommendations and had regular follow-up appointments with 12-lead ECG; the majority of them were also screened with 12-HPL Holter. Medical notes and tracings were reviewed to identify a dynamic spT1-BrS and events at f-up (SCD/appropriate ICD shock). Results The mean age at presentation was 44±15 years; 52% of participants were males. All had at least 2 resting ECGs recorded; in 281 subjects at least one 12-HPL Holter was available (total 643, median 2, range 1-8). Over a median follow-up of 66 months (IQR 75), 37 subjects in Group 2 showed a spT1-BrS at least once: 10 during a repeat resting ECG, 2 during/after exercise tolerance test, 25 at 12-HPL Holter. The average time at spT1 appearance during follow-up was 23 months (range 1- 225). Those with a newly detected spT1-BrS were more frequently males and less likely to have a familial history of sudden cardiac death (Table 1). Excluding subjects with previous aCA/documented VT, 6 events occurred at f-up, all in subjects with spT1 (Figure 1). Univariate models showed that the presence of a spT1-BrS pattern was consistently associated with increased risk of events (at presentation: HR 10, 95% C.I. 1.8-54; at follow-up: HR 5.3, 95% C.I. 1.6-17). Conclusions A spontaneous T1-BrS can be detected in up to 12% of subjects with concealed BrS at presentation using 12-HPL Holter monitoring. Its presence is consistently associated with arrhythmic risk at f-up up, regardless of the time at detection. Prolonged ambulatory ECG monitoring is fundamental for risk stratification in this population.

P60 THE ELECTROPHYSIOLOGICAL DIAGNOSIS OF THE CRYPTOGENETIC STROKE

Abstract Introduction In the neurological field, one of the pathologies not yet fully clarified from an etiopathogenetic point of view is cryptogenic stroke. This definition applies to all those forms of stroke in which clinical–instrumental investigations have not been able to define the "primum movens". In the literature, a significant percentage of cryptogenic stroke is the result of Paroxysmal Atrial Fibrillation (FAP). Currently the recognition of asymptomatic and rapidly evolving forms of AF can be investigated with the use of implantable electrocardiographic recorders (Loop Recorder or ILR) which increase the recognition rate of AF compared to standard investigations. The Loop Recorders, monitoring the electrical activity of the heart, are automatically activated and record the event. This data, thanks to a transmission system, as well as being stored in the memory of the recorder and therefore being interrogated, is sent to a central server which in turn transmits it to the control room which stores the patient and the events remotely. Objectives To diagnose the cause of the cryptogenic Stroke through the implantation of the ILR with long–term monitoring, up to 36 months. Methods All patients admitted to the Stroke Unit with cryptogenic stroke were evaluated with the ESUS SCORE. Patients who tested positive at the administration of the score underwent Loop Recorder (ILR) implantation for prolonged cardiac monitoring in the clinical suspicion of FAP as the cause of cryptogenic stroke. The results of such monitoring were documented along with the duration of hospital cardiac monitoring. Results A total of 210 patients diagnosed with ischemic stroke or transient ischemic attack (TIA) were identified. Of the strokes, 22 (10.4%) were classified as cryptogenic. These patients underwent a Loop Recorder implant and were monitored for 12 months. 6 out of 22 patients (27.2%) were affected by atrial fibrillation and were treated with warfarin. Conclusion Continuous Loop Recorder monitoring changed the drug treatment of 27.2% of cryptogenic stroke patients due to intermittent AF detection despite no AF detection by electrocardiography and in–hospital telemetry monitoring.

P323 WELLENS PATTERN, MYOCARDIAL BRIDGING, AND BIVENTRICULAR ARRHYTHMOGENIC CARDIOMYOPATHY: A SINGLE "TRIPLE" DIAGNOSIS

Abstract Wellens‘ syndrome describes an electrocardiographic pattern characterized by T–wave changes in the antero–septal leads that make this finding highly suggestive of a lesion of the proximal segment of the anterior interventricular artery. Case report. A 58–year–old patient from China with a silent medical history presented to the emergency department with angor, dizziness, asthenia, and blurred vision. The electrocardiogram shows a Wellens type A pattern, and blood chemistry tests collected in the emergency department show liver, kidney function and blood count within normal limits. High–sensitivity troponin T values stand at 34 ng/mL. The echocardiogram shows preserved biventricular systolic function in the absence of major regional wall motion abnormality. Given the symptoms, troponin values, and electrocardiographic pattern, the patient underwent coronary angiopgraphy, which showed lesion–free epicardial coronary arteries but with a muscular bridge in the mid–proximal section of the anterior interventricular artery, with no obvious significant systolic–diastolic caliber changes at subsequent coronary CT analysis. To better assess possible myocardial ischemic damage, the patient underwent MRI (magnetic resonance), which showed an entirely unexpected result. In fact, T1 sequences revealed biventricular adipose infiltration at the anterolateral and inferolateral walls of the left ventricle, with homosedial enhancement to nonischemic pattern on late post–contrast images: this picture was considered suggestive of biventricular arrhythmogenic cardiomyopathy. In the absence of history of syncope and documented arrhythmias on prolonged rhythm monitoring during hospitalization, no indication was made for further diagnostic and therapeutic investigations from the arrhythmological point of view. Thus, beta blocker and ace inhibitor therapy was set, and the patient was started on an outpatient cardiology follow–up course and genetic counseling for him and first–degree family members was scheduled. Selecting the correct imaging method becomes crucial for a correct diagnosis, especially in cases in which symptomatology is inconclusive.