Abstract only Introduction: Cryptogenic strokes account for one third of all strokes. Atrial fibrillation has been described as a leading cause in this population but occurrence of atrial ...fibrillation and imaging charecteristics amongst recurrent strokes in this population have not been characterized well. Methods: We reviewed electronic medical charts of a cohort of cryptogenic patients from February 2014 to September 2017 who underwent REVEAL LINQ insertable cardiac monitor. All patients met ESUS( Embolic Stroke of Unknown Source) criteria prior to implantation and were enrolled in the atrial fibrillation clinic with structured remote follow-up. All newly diagnosed atrial fibrillation was confirmed by electrophysiologists and recurrent strokes were confirmed by vascular neurologist after reviewing presentation, electronic medical record and brain imaging studies. Results: Atrial fibrillation was detected in 108 out of a total of 429 patients ( 25%) . Time to atrial fibrillation detection was average 79.8 days with a range of 13-430 days . All but one patient were started on anticoagulation. Within the entire cohort 55 patients had recurrent strokes with 7 of them having more than 1 recurrence.. 15 recurrent strokes occurred in patients in whom atrial fibrillation was detected during monitoring and 40 in patients without atrial fibrillation detected . Imaging pattern of recurrent strokes in patients with atrial fibrillation was cortical in 81.8% with 10 patients showing multiple infarcts and subcortical in 18.2% patients with one showing multiple infarcts. Strokes in patients without atrial fibrillation were cortical in location in 60% with 10 being multiple and subcortical in 40% with 3 patient having multiple infarcts.4 patients who did not have atrial fibrillation had more than 1 recurrent stroke and 3 patients who were detected to have atrial fibrillation had more than 1 recurrent stroke Conclusion majority of recurrent strokes in cryptogenic population did not have atrial fibrillation( 72.7%) Incidence of recurrent stroke was similar in patients with atrial fibrillation (13.8%) detected versus (12.4% %)not detected group . Imaging patterns showed more cortical strokes in A. fib patients ( 80%) and more subcortical strokes in patients without A. fib( 40%)
Abstract only Introduction: Paroxysmal afib is the most common cause of cryptogenic strokes. Long-term insertable cardiac monitor (ICM) has been increasingly used for ongoing evaluation of afib in ...these patients. Due to financial affordability, it is important to identify appropriate candidates for its routine use. Methods: We reviewed EMRs of a cohort of cryptogenic stroke patients from February 2014 to May 2017 who received REVEAL LINQ ICMs. All patients met ESUS criteria prior to insertion and were enrolled in remote follow-up. At least one year monitoring was conducted if no afib was recorded. Patient demographics, stroke characteristics and risk factors were compared between patients with and without afib. Results: Among total 348 patients enrolled, 99 (28.5%) were found to have afib with median time to afib detection of 128 days. For patients without afib, the median length of follow up was 566 days. Patients with afib were significantly older (mean ± SD, 73.0 ± 9.42 vs. 64.4 ± 11.5, p<0.00001) and their left atrium size (mm) were significantly larger (37.9 ± 7.26 vs. 35.4 ± 5.81, p<0.005) than those patients without afib. Non-afib patients had statistically more frequent association with ongoing smoking or LDL ≥ 120 comparing with afib patients (p<0.05). Although not statistically significant, there was tendency that posterior circulation only strokes occurred less in afib group (p=0.08). However, intra- and extracranial atherosclerosis were comparable between afib and non-afib groups. Within the afib group, afib was detected within 30 days in 25 patients with median time to detection of 14 days. These patients had significant higher rate of intracranial stenosis (p=0.01) comparing with those patients with afib detected beyond 30 days. Conclusion: Paroxysmal afib related strokes account for about one-fourth of cryptogenic strokes in our cohort. Long term ICM may benefit more in older patients with enlarged left atrium and lack of risk factors such as smoking and high LDL. It likely has low yield in patients with posterior infarcts only. Noninvasive ambulatory ECG monitoring for 30 days may be considered first in patients with intracranial stenosis.
IMPORTANCE: Patients with ischemic stroke attributed to large- or small-vessel disease are not considered at high risk for atrial fibrillation (AF), and the AF incidence rate in this population is ...unknown. OBJECTIVES: To determine whether long-term cardiac monitoring is more effective than usual care for AF detection in patients with stroke attributed to large- or small-vessel disease through 12 months of follow-up. DESIGN, SETTING, AND PARTICIPANTS: The STROKE-AF trial was a randomized (1:1), multicenter (33 sites in the US) clinical trial that enrolled 496 patients between April 2016 and July 2019, with primary end point follow-up through August 2020. Eligible patients were aged 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor and had an index stroke attributed to large- or small-vessel disease within 10 days prior to insertable cardiac monitor (ICM) insertion. INTERVENTIONS: Patients randomized to the intervention group (n = 242) received ICM insertion within 10 days of the index stroke; patients in the control group (n = 250) received site-specific usual care consisting of external cardiac monitoring, such as 12-lead electrocardiograms, Holter monitoring, telemetry, or event recorders. MAIN OUTCOMES AND MEASURES: Incident AF lasting more than 30 seconds through 12 months. RESULTS: Among 492 patients who were randomized (mean SD age, 67.1 9.4 years; 185 37.6% women), 417 (84.8%) completed 12 months of follow-up. The median (interquartile range) CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category) score was 5 (4-6). AF detection at 12 months was significantly higher in the ICM group vs the control group (27 patients 12.1% vs 4 patients 1.8%; hazard ratio, 7.4 95% CI, 2.6-21.3; P < .001). Among the 221 patients in the ICM group who received an ICM, 4 (1.8%) had ICM procedure–related adverse events (1 site infection, 2 incision site hemorrhages, and 1 implant site pain). CONCLUSIONS AND RELEVANCE: Among patients with stroke attributed to large- or small-vessel disease, monitoring with an ICM compared with usual care detected significantly more AF over 12 months. However, further research is needed to understand whether identifying AF in these patients is of clinical importance. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02700945
In patients with acute minor ischemic stroke or high-risk transient ischemic attack enrolled in the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke POINT Trial), the ...combination of clopidogrel and aspirin for 90 days reduced major ischemic events but increased major hemorrhage in comparison to aspirin alone.
In a secondary analysis of POINT (N=4881), we assessed the time course for benefit and risk from the combination of clopidogrel and aspirin. The primary efficacy outcome was a composite of ischemic stroke, myocardial infarction, or ischemic vascular death. The primary safety outcome was major hemorrhage. Risks and benefits were estimated for delayed times of treatment initiation using left-truncated models.
Through 90 days, the rate of major ischemic events was initially high then decreased markedly, whereas the rate of major hemorrhage remained low but relatively constant throughout. With the use of a model-based approach, the optimal change point for major ischemic events was 21 days (0-21 days hazard ratio 0.65 for clopidogrel-aspirin versus aspirin; 95% CI, 0.50-0.85; P=0.0015, in comparison to 22-90 days hazard ratio, 1.38; 95% CI, 0.81-2.35; P=0.24). Models showed benefits of clopidogrel-aspirin for treatment delayed as long as 3 days after symptom onset.
The benefit of clopidogrel-aspirin occurs predominantly within the first 21 days, and outweighs the low, but ongoing risk of major hemorrhage. When considered with the results of the CHANCE trial (Clopidogrel in High-Risk Patients With Non-disabling Cerebrovascular Events), a similar trial treating with clopidogrel-aspirin for 21 days and showing no increase in major hemorrhage, these results suggest that limiting clopidogrel-aspirin use to 21 days may maximize benefit and reduce risk after high-risk transient ischemic attack or minor ischemic stroke.
URL: https://www.clinicaltrials.gov. Unique identifier: NCT00991029.
BACKGROUND:In patients with acute minor ischemic stroke or high-risk transient ischemic attack enrolled in the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke POINT ...Trial), the combination of clopidogrel and aspirin for 90 days reduced major ischemic events but increased major hemorrhage in comparison to aspirin alone.
METHODS:In a secondary analysis of POINT (N=4881), we assessed the time course for benefit and risk from the combination of clopidogrel and aspirin. The primary efficacy outcome was a composite of ischemic stroke, myocardial infarction, or ischemic vascular death. The primary safety outcome was major hemorrhage. Risks and benefits were estimated for delayed times of treatment initiation using left-truncated models.
RESULTS:Through 90 days, the rate of major ischemic events was initially high then decreased markedly, whereas the rate of major hemorrhage remained low but relatively constant throughout. With the use of a model-based approach, the optimal change point for major ischemic events was 21 days (0–21 days hazard ratio 0.65 for clopidogrel-aspirin versus aspirin; 95% CI, 0.50–0.85; P=0.0015, in comparison to 22–90 days hazard ratio, 1.38; 95% CI, 0.81–2.35; P=0.24). Models showed benefits of clopidogrel-aspirin for treatment delayed as long as 3 days after symptom onset.
CONCLUSIONS:The benefit of clopidogrel-aspirin occurs predominantly within the first 21 days, and outweighs the low, but ongoing risk of major hemorrhage. When considered with the results of the CHANCE trial (Clopidogrel in High-Risk Patients With Non-disabling Cerebrovascular Events), a similar trial treating with clopidogrel-aspirin for 21 days and showing no increase in major hemorrhage, these results suggest that limiting clopidogrel-aspirin use to 21 days may maximize benefit and reduce risk after high-risk transient ischemic attack or minor ischemic stroke.
CLINICAL TRIAL REGISTRATION:URLhttps://www.clinicaltrials.gov. Unique identifierNCT00991029.
Use of implantable cardiac monitors (ICMs) has increased diagnosis of atrial fibrillation (AF) in cryptogenic stroke (CS) patients. Identifying AF predictors may enhance the yield of AF detection. ...Recurrent strokes after CS are not well described. We aimed to assess the predictors for AF detection and the characteristics of recurrent strokes in patients after CS.
We reviewed electronic medical records of CS patients who were admitted between February 2014 and September 2017 and underwent ICM placement with minimum one-year follow-up. Patient demographics, stroke characteristics, pre-defined risk factors as well as recurrent strokes were compared between patients with and without AF detection.
389 patients with median follow-up of 548 days were studied. AF was detected in 102 patients (26.2%). Age (per decade increase, OR 2.10, CI 1.64–2.68, with vs. without AF) and left atrium diameter (per 5 mm increase, OR 1.91, CI 1.33–2.74) were identified as AF predictors. Intracranial large vessel stenosis >50% irrelevant to the index strokes was associated with AF detection within 30 days (OR 0.24, CI 0.09–0.69, >30 vs. <30 days). Recurrent strokes occurred in 14% patients with median follow-up about 2.5 years. Topography of these strokes resembled embolic pattern and was comparable between patients with and without AF. Among recurrent strokes in patients with AF, the median time to AF detection was much shorter (90 vs. 251 days), and the median time to first stroke recurrence was much longer (422 vs. 76 days) in patients whose strokes recurred after AF detection than those before AF detection.
Older age and enlarged left atrium are predictors for AF detection in CS patients. Intracranial atherosclerosis is more prevalent in patients with early AF detection within 30 days. Recurrent strokes follow the embolic pattern, and early AF detection could delay the stroke recurrence.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
IntroductionEmbolic strokes related to atrial fibrillation (AF) carry significant morbidity and mortality. Identifying patients with asymptomatic AF following stroke is difficult. A protocol for ...incorporation of implantable loop recorders (ILR) in stroke management has not been established.MethodsWe developed a protocol for evaluation of patients with cryptogenic embolic stroke using ILR for detection of AF (figure 1). Patients implanted with ILR were enrolled in an AF clinic with structured remote follow-up. The primary end point was time to first detected AF. Secondary end point was time to initiation of anticoagulation following identification of AF.Results95 patients underwent ILR placement. Baseline characteristics are shown in table 1.The median time between stroke and ILR placement was 6 days with a range of 1 to 496 days. The mean follow-up time was 169.4 +/- 103.1days. 18 patients (18.9%) had AF detected during the study period (Figure 2). Mean time to detection of AF was 95.7 +/- 93.6 days. 94.4% were anticoagulated (52.9% Rivaroxaban, 41.2% Apixaban, 5.9% Warfarin). The median time from detection of AF to initiation of anticoagulation was 2 days with a range of 1 to 28 days.ConclusionsA protocol for incorporating ILR in evaluation of embolic cryptogenic stroke can improve AF detection and time to initiation of anticoagulation.
IMPORTANCE: The STROKE AF study found that in patients with prior ischemic stroke attributed to large-artery atherosclerotic disease (LAD) or small-vessel occlusive disease (SVD), 12% developed AF ...over 1 year when monitored with an insertable cardiac monitor (ICM). The occurrence over subsequent years is unknown. OBJECTIVES: To compare the rates of AF detection through 3 years of follow-up between an ICM vs site-specific usual care in patients with prior ischemic stroke attributed to LAD or SVD. DESIGN, SETTING, AND PARTICIPANTS: This multicenter, randomized (1:1) clinical trial took place at 33 sites in the US with enrollment between April 2016 and July 2019 and 3-year follow-up through July 2022. Eligible patients were aged 60 years or older, or aged 50 to 59 years with at least 1 additional stroke risk factor and had an index ischemic stroke attributed to LAD or SVD within 10 days prior to ICM insertion. Of the 496 patients enrolled, 492 were randomized and 4 were excluded. INTERVENTIONS: ICM monitoring vs site-specific usual care. MAIN OUTCOMES AND MEASURES: The prespecified long-term outcome of the trial was AF detection through study follow-up (up to 3 years). AF was defined as an episode lasting more than 30 seconds, adjudicated by an expert committee. RESULTS: In total, 492 patients were randomized and included in the analyses (median IQR age, 66 60-74 years; 307 men 62.4% and 185 women 37.6%), of whom 314 completed 3-year follow-up (63.8%). The incidence rate of AF at 3 years was 21.7% (46 patients) in the ICM group vs 2.4% (5 patients) in the control group (hazard ratio, 10.0; 95% CI, 4.0-25.2; P < .001). CONCLUSIONS AND RELEVANCE: Patients with ischemic stroke attributed to LAD or SVD face an increasing risk of AF over time and most of the AF occurrences are not reliably detected by standard medical monitoring methods. One year of negative monitoring should not reassure clinicians that patients who have experienced stroke will not develop AF over the next 2 years. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02700945
IMPORTANCE: The Stroke of Known Cause and Underlying Atrial Fibrillation (STROKE AF) trial found that approximately 1 in 8 patients with recent ischemic stroke attributed to large- or small-vessel ...disease had poststroke atrial fibrillation (AF) detected by an insertable cardiac monitor (ICM) at 12 months. Identifying predictors of AF could be useful when considering an ICM in routine poststroke clinical care. OBJECTIVE: To determine the association between commonly assessed risk factors and poststroke detection of new AF in the STROKE AF cohort monitored by ICM. DESIGN, SETTING, AND PARTICIPANTS: This was a prespecified analysis of a randomized (1:1) clinical trial that enrolled patients between April 1, 2016, and July 12, 2019, with primary follow-up through 2020 and mean (SD) duration of 11.0 (3.0) months. Eligible patients were selected from 33 clinical research sites in the US. Patients had an index stroke attributed to large- or small-vessel disease and were 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor. A total of 496 patients were enrolled, and 492 were randomly assigned to study groups (3 did not meet inclusion criteria, and 1 withdrew consent). Patients in the ICM group had the index stroke within 10 days before insertion. Data were analyzed from October 8, 2021, to January 28, 2022. INTERVENTIONS: ICM monitoring vs site-specific usual care (short-duration external cardiac monitoring). MAIN OUTCOMES AND MEASURES: The ICM device automatically detects AF episodes 2 or more minutes in length; episodes were adjudicated by an expert committee. Cox regression multivariable modeling included all parameters identified in the univariate analysis having P values <.10. AF detection rates were calculated using Kaplan-Meier survival estimates. RESULTS: The analysis included the 242 participants randomly assigned to the ICM group in the STROKE AF study. Among 242 patients monitored with ICM, 27 developed AF (mean SD age, 66.6 9.3 years; 144 men 60.0%; 96 40.0% women). Two patients had missing baseline data and exited the study early. Univariate predictors of AF detection included age (per 1-year increments: hazard ratio HR, 1.05; 95% CI, 1.01-1.09; P = .02), CHA2DS2-VASc score (per point: HR, 1.54; 95% CI, 1.15-2.06; P = .004), chronic obstructive pulmonary disease (HR, 2.49; 95% CI, 0.86-7.20; P = .09), congestive heart failure (CHF; with preserved or reduced ejection fraction: HR, 6.64; 95% CI, 2.29-19.24; P < .001), left atrial enlargement (LAE; HR, 3.63; 95% CI, 1.55-8.47; P = .003), QRS duration (HR, 1.02; 95% CI, 1.00-1.04; P = .04), and kidney dysfunction (HR, 3.58; 95% CI, 1.35-9.46; P = .01). In multivariable modeling (n = 197), only CHF (HR, 5.06; 95% CI, 1.45-17.64; P = .05) and LAE (HR, 3.32; 1.34-8.19; P = .009) remained significant predictors of AF. At 12 months, patients with CHF and/or LAE (40 of 142 patients) had an AF detection rate of 23.4% vs 5.0% for patients with neither (HR, 5.1; 95% CI, 2.0-12.8; P < .001). CONCLUSIONS AND RELEVANCE: Among patients with ischemic stroke attributed to large- or small-vessel disease, CHF and LAE were associated with a significantly increased risk of poststroke AF detection. These patients may benefit most from the use of ICMs as part of a secondary stroke prevention strategy. However, the study was not powered for clinical predictors of AF, and therefore, other clinical characteristics may not have reached statistical significance. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02700945
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