Prolonged Cardiac Monitoring and Stroke Recurrence

 So you wrote this up as a protocol and distributed it to all stroke hospitals in the world? Where can I find that protocol?  Just writing this stuff in a journal does nothing to get it into the correct hands that will implement it.

Prolonged Cardiac Monitoring and Stroke Recurrence

A Meta-analysis

Georgios Tsivgoulis, Sokratis Triantafyllou, Lina Palaiodimou, Brian Mac Grory, Spyridon Deftereos, Martin Köhrmann, View ORCID ProfilePolychronis Dilaveris, Brittany Ricci, Konstantinos Tsioufis, Shawna Cutting, View ORCID ProfileGkikas Magiorkinis, View ORCID ProfileChristos Krogias, Peter D. Schellinger, Efthymios Dardiotis, Ana Rodriguez-Campello, Elisa Cuadrado-Godia, View ORCID ProfileDiana Aguiar de Sousa, View ORCID ProfileMukul Sharma, David J. Gladstone, Tommaso Sanna, View ORCID ProfileRolf Wachter, Karen L. Furie, Andrei V. Alexandrov, Shadi Yaghi, Aristeidis H. Katsanos

First published March 9, 2022, DOI: https://doi.org/10.1212/WNL.0000000000200227

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Abstract

Background and Objectives Prolonged poststroke cardiac rhythm monitoring (PCM) reveals a substantial proportion of patients with ischemic stroke (IS) with atrial fibrillation (AF) not detected by conventional rhythm monitoring strategies. We evaluated the association between PCM and the institution of stroke preventive strategies and stroke recurrence.

Methods We searched MEDLINE and SCOPUS databases to identify studies reporting stroke recurrence rates in patients with history of recent IS or TIA receiving PCM compared with patients receiving conventional cardiac rhythm monitoring. Pairwise meta-analyses were performed under the random effects model. To explore for differences between the monitoring strategies, we combined direct and indirect evidence for any given pair of monitoring devices assessed within a randomized controlled trial (RCT).

Results We included 8 studies (5 RCTs, 3 observational; 2,994 patients). Patients receiving PCM after their index event had a higher rate of AF detection and anticoagulant initiation in RCTs (risk ratio [RR] 3.91, 95% CI 2.54–6.03; RR 2.16, 95% CI 1.66–2.80, respectively) and observational studies (RR 2.06, 95% CI 1.57–2.70; RR 2.01, 95% CI 1.43–2.83, respectively). PCM was associated with a lower risk of recurrent stroke during follow-up in observational studies (RR 0.29, 95% CI 0.15–0.59), but not in RCTs (RR 0.72, 95% CI 0.49–1.07). In indirect analyses of RCTs, the likelihood of AF detection and anticoagulation initiation was higher for implantable loop recorders compared with Holter monitors and external loop recorders.

Discussion PCM after an IS or TIA can lead to higher rates of AF detection and anticoagulant initiation. There is no solid RCT evidence supporting that PCM may be associated with lower stroke recurrence risk.

Glossary

AF=

atrial fibrillation;

AHA=

American Heart Association;

ASA=

American Stroke Association;

ESC=

European Society of Cardiology;

ESUS=

embolic stroke of undetermined source;

ICH=

intracranial hemorrhage;

ILR=

implantable loop recorder;

IS=

ischemic stroke;

NMA=

network meta-analysis;

PCM=

poststroke cardiac rhythm monitoring;

RCT=

randomized controlled trial;

RR=

risk ratio;

SUCRA=

surface under the cumulative ranking