Cross-Sectional Retrospective Study to Identify Clinical and Radiographic Features Associated With VZV Reactivation in Cryptogenic Stroke Patients With CSF Testing

FYI. But they still asked for additional research. Since we have NO strategy to update and NO leadership to contact, NOTHING WILL BE DONE. That is how bad the failures are in the stroke medical world,

Cross-Sectional Retrospective Study to Identify Clinical and Radiographic Features Associated With VZV Reactivation in Cryptogenic Stroke Patients With CSF Testing

 

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Ekaterina Bakradze, MD, Charles C. Esenwa, MD, MS, D. Scott Schmid, PhD, ...

First Published February 23, 2022 Research Article 

https://doi.org/10.1177/19418744221075123

Article information

Abstract

Background and Purpose:

A large proportion of ischemic stroke patients lack a definitive stroke etiology despite extensive diagnostic testing. Varicella-Zoster Virus (VZV) can directly invade blood vessels causing vasculitis and may be associated with cryptogenic stroke (CS).

Methods:

We conducted a retrospective cross-sectional study of CS patients tested for VZV. The following were considered evidence of VZV reactivation (VZV+): positive CSF VZV PCR, anti-VZV IgM in CSF, or anti-VZV IgG CSF/serum ratio of 1:10 or higher. We describe the cohort, report VZV+ proportion with 95% confidence intervals (CI) determined with the Wald method, and compare patient groups using standard statistical tests.

Results:

A total of 72 CS patients met full study inclusion criteria. Most of the patients were <65 years old, had few traditional vascular risk factors, and had multifocal infarcts. Mean age was 49 years (SD ±13) and 47% were women. A total of 14 patients (19.4%; CI: 11.4-30.8%) had evidence of CNS VZV reactivation. There was no difference in evaluated demographic or radiographic features between those with versus without evidence of VZV reactivation. History of ischemic stroke in the past year (11/14 vs 25/43, P<.05) and hypertension (13/14 vs 35/58 and P<.05) were associated with VZV+.

Conclusion:

We found a high proportion of CNS VZV reactivation in a cross-sectional cohort of CS patients selected for CSF testing. Testing for VZV might be reasonable in CS patients who are young, have multifocal infarcts, or had an ischemic stroke within the past year, but additional research is needed.

Keywords

ischemic stroke, vasculitis, cryptogenic stroke, varicella zoster virus

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A Nomogram for Predicting Patent Foramen Ovale-Related Stroke Recurrence

Good luck understanding anything here. But the takeaway is to not have a cryptogenic stroke since your doctor has nothing to prevent the next one.

Nomogram: diagram representing the relations between three or more variable quantities by means of a number of scales, so arranged that the value of one variable can be found by a simple geometric construction, for example, by drawing a straight line intersecting the other scales at the appropriate values.

A Nomogram for Predicting Patent Foramen Ovale-Related Stroke Recurrence

Zhuonan Wu^1†, Chuanjing Zhang^2†, Nan Liu³, Wenqing Xie³, Jinjin Yang⁴, Hangyuan Guo⁵ and Jufang Chi^5*

• ¹Shaoxing University School of Medicine, Shaoxing, China
• ²Ningbo University School of Medicine, Ningbo, China
• ³Zhejiang Chinese Medical University of Medicine, Hangzhou, China
• ⁴Zhejiang University School of Medicine, Hangzhou, China
• ⁵Department of Cardiology, The First Affiliated Hospital of Shaoxing University (Shaoxing People's Hospital), Shaoxing, China

Background: The high prevalence of patent foramen ovale (PFO) in cryptogenic stroke suggested a stroke-causing role for PFO. As risk factors for recurrence of such stroke are not recognized, clinicians cannot sufficiently identify, treat, and follow-up high-risk patients. Therefore, this study aimed to establish a prediction model for PFO-related stroke recurrence.

Methods: This study included 392 patients with PFO-related stroke in a training set and 164 patients with PFO-related stroke in an independent validation set. In the training set, independent risk factors for recurrence identified using forward stepwise Cox regression were included in nomogram 1, and those identified using least absolute shrinkage and selection operator(LASSO)regression were included in nomogram 2. Nomogram performance and discrimination were assessed using the concordance index (C-index), area under the curve (AUC), calibration curve, and decision curve analyses (DCA). The results were also validated in the validation set.

Results: Nomogram 1 was based on homocysteine (Hcy), high-sensitivity C-reactive protein (hsCRP), and albumin (ALB), and nomogram 2 was based on age, diabetes, hypertension, right-to-left shunt, ALB, prealbumin, hsCRP, and Hcy. The C-index of nomogram 1 was 0.861, which was not significantly different from that of nomogram 2 (0.893). The 2- and 5-year AUCs of nomogram 1 were 0.863 and 0.777, respectively. In the validation set, nomogram 1 still had good discrimination (C-index, 0.862; 2-year AUC, 0.839; 5-year AUC, 0.990). The calibration curve showed good homogeneity between the prediction by nomogram 1 and the actual observation. DCA demonstrated that nomogram 1 was clinically useful. Moreover, patients were successfully divided into two distinct risk groups (low and high risk) for recurrence rate by nomogram 1.

Conclusions: Nomogram 1, based on Hcy, hsCRP, and ALB levels, provided a more clinically realistic prognostic prediction for patients with PFO-related stroke. This model could help patients with PFO-related stroke to facilitate personalized prognostic evaluations.

Introduction

Approximately 30–40% of ischemic strokes are known as “cryptogenic strokes” because they have no identified cause (1). In the last century, epidemiological surveys have found a significantly higher prevalence of patent foramen ovale (PFO) in the cryptogenic stroke population than in the normal population, suggesting a stroke-causing role for PFO (2). The main mechanism of PFO-related stroke is currently believed to be paradoxical embolism, in which a thrombus from the vein (especially the deep vein of the lower extremity) travels through the venous system to the right atrium and through the PFO to the left atrium, which is known as a right-to-left shunt (RLS), then the thrombus followed by blood flow into cerebral arteries, leading to stroke. In 2017, the publication of the results of the RESPECT long-term follow-up, the CLOSE trial, and the Gore-REDUCE trial verified that PFO can cause stroke and strongly demonstrated that PFO closure is superior to drug treatment alone in reducing the recurrence of PFO-related stroke (3–5). Consequently, scholars formally proposed the concept of “PFO-related stroke” in 2020 (6). Although PFO closure resulted in a relative (65%) reduction in the risk of stroke recurrence compared with antiplatelet treatment alone (7), the relatively low absolute recurrence rate of PFO-related stroke itself and the lack of accurate assessment of patient prognosis allow that a large number of patients remain on conservative drug therapy and some even remain untreated. Despite the absence of data on the long-term risk of stroke recurrence (>10 years) in patients with PFO-related stroke receiving drug therapy, more than 50% of patients were followed up for 5 years or longer. In these trials (3), the Kaplan-Meier curves for drug treatment did not show a decrease in the rate of stroke recurrence over time. In some studies, the annual recurrence rate of PFO-related stroke remained as high as approximately 4.8%, and this figure even increased to 8.2% in some patients with PFO-related stroke (8). Therefore, it is essential to identify the population at a high risk of PFO-related stroke recurrence, which is also a current clinical limitation. There is no consensus regarding risk factors for PFO-related stroke recurrence or clinically available biological markers. Although some studies have identified larger PFO size, larger RLS, atrial septal aneurysm (ASA), and high homocysteine (Hcy) levels as risk factors for PFO-related stroke recurrence, there is still a lack of consistent understanding and integration of risk scores for each independent risk factor.

More at link.

 

Stroke Prevention After Cryptogenic Stroke

 You can't let your doctor get by with not figuring out THE EXACT REASON FOR YOUR STROKE. Damned difficult to prevent the next one if your doctor fails at finding the reason.

Stroke Prevention After Cryptogenic Stroke

• Chinwe Ibeh &
• Mitchell S. V. Elkind 

Current Cardiology Reports volume 23, Article number: 174 (2021) Cite this article

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Abstract

Purpose of Review

Cryptogenic stroke represents a heterogenous but clinically important collection of stroke etiologies for which our understanding continues to grow. Here, we review our current knowledge and most recent recommendations on secondary prevention for common causes of cryptogenic stroke including paroxysmal atrial fibrillation, atrial cardiopathy, patent foramen ovale, and substenotic atherosclerotic disease as well as the under-recognized mechanisms of occult malignancy, heart failure, and, most recently, infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).

Recent Findings

The results from recent observational studies and randomized clinical trials have provided greater insight into the causal relationship and attributable risk of these suspected etiologies and have identified potential strategies to reduce the rates of recurrence. However, further clinical trials are needed to confirm the benefits of specific stroke prevention strategies, including the patient populations most likely to benefit from anticoagulation.

Summary

There is ongoing research aimed at both reducing the proportion of ischemic strokes classified as cryptogenic and resolving much of the clinical equipoise that still exists. The results of these studies have the potential to provide us with a better understanding of these occult mechanisms and allow for more targeted interventions.

Introduction

Ischemic strokes can result from several different mechanisms, the majority of which can be readily identified following a standard diagnostic evaluation. However, in about 25% of cases stroke etiology remains unknown—a clinically important point as the effectiveness of secondary prevention strategies often hinges on accurate and timely identification of the underlying cause [1]. Our understanding of cryptogenic stroke has evolved through the years and depends on the classification system used. An early and commonly used system arose from the TOAST (Trial of Org 10,172 in Acute Stroke Treatment) study which classified ischemic strokes based on five potential etiologies: [1] large artery atherosclerosis, [2] cardioembolism, [3] small vessel occlusion, [4] other determined etiology (e.g., dissection), or [5] of undetermined source (i.e., cryptogenic) [2]. According to the TOAST system, strokes could be classified as cryptogenic [1] after an extensive evaluation, [2] after an incomplete evaluation, or [3] due to the presence of multiple competing etiologies. The simplicity of the system has made it widely popular for use in both clinical practice and scientific research. However, through the years, as stroke research has evolved (along with our standards for optimal care), TOAST’s broad inclusion criteria for cryptogenic stroke has complicated efforts towards targeted medical management. Since then additional classification systems have been developed, emphasizing underlying mechanisms (causative) and/or disease manifestations (phenotypic) (Table 1) [2,3,4]. In an attempt to identify a single and therapeutically distinct subset of patients with cryptogenic stroke, Hart and colleagues proposed the concept of ESUS, or embolic stroke of undetermined source, broadly defined as nonlacunar brain infarcts occurring in the absence of [1] ≥ 50% luminal atherosclerotic stenosis of the supplying extracranial or intracranial arteries, [2] any major-risk cardioembolic source, and [3] any other specific cause of stroke (e.g., dissection, vasospasm, drug abuse) [5]. With this distinction, the authors proposed there was likely a subset of cryptogenic strokes that were more likely embolic in origin and perhaps more likely to respond to anticoagulant therapy. However, even with these new constructs, cryptogenic stroke remains a diagnostic challenge. As the 10-year risk of recurrence is estimated to be as high as 30%, investigations into potential sources of cryptogenic stroke should be focused and deliberate—guided by patient factors and clinical features aimed at increasing the yield of diagnostic studies and identifying patients who would likely benefit from targeted therapies [6].

Table 1 Summary of ischemic stroke classification systems

Full size table

In the last 5 years, several clinical trials have investigated the efficacy of newer therapies for specific conditions often implicated in cryptogenic stroke. Non-vitamin K oral antagonists (NOACs), such as dabigatran, rivaroxaban, and apixaban have been explored in patients with ESUS, heart failure, and malignancy with varying degrees of success [7, 8••, 9•]. The results of these studies have inspired additional trials using these new agents in more select sub-populations. In addition, the recent CLOSE, REDUCE, and DEFENSE-PFO studies identified patients with cryptogenic stroke and PFO who may benefit most from PFO closure, prompting a recent update in the recommendations from the American Academy of Neurology [10,11,12]. Although these discoveries highlight recent progress in the area of cryptogenic stroke, their gaps and limitations emphasize the need for continued work into interventions that may further reduce the risk of recurrence in these special populations.

 More at link.

Prevalence, Characteristics, and Outcomes of Undetermined Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

 This obviously means your doctors and stroke hospitals are not providing any information to a central database of stroke outcomes. The failure on that is directly tied to our fucking failures of stroke associations doing nothing useful.

 

Prevalence, Characteristics, and Outcomes of Undetermined Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

Konark Malhotra

,

Christina Zompola

,

Aikaterini Theodorou

,

Aristeidis H. Katsanos

,

Ashkan Shoamanesh

,

Himanshu Gupta

,

Simon Beshara

,

Nitin Goyal

,

Jason Chang

, … See all authors

Originally published4 Aug 2021https://doi.org/10.1161/STROKEAHA.120.031471Stroke. ;0:STROKEAHA.120.031471

Abstract

Background and Purpose:

There are scarce data regarding the prevalence, characteristics and outcomes of intracerebral hemorrhage (ICH) of undetermined (unknown or cryptogenic) etiology. We sought to determine the prevalence, radiological characteristics, and clinical outcomes of undetermined ICH.

Methods:

Systematic review and meta-analysis of studies involving patients with spontaneous ICH was conducted to primarily assess the prevalence and clinical-radiological characteristics of undetermined ICH. Additionally, we assessed the rates for ICH secondary to hypertensive arteriopathy and cerebral amyloid angiopathy. Subgroup analyses were performed based on the use of (1) etiology-oriented ICH classification, (2) detailed neuroimaging, and (3) Boston criteria among patients with cerebral amyloid angiopathy related ICH. We pooled the prevalence rates using random-effects models, and assessed the heterogeneity using Cochran Q and I² statistics.

Results:

We identified 24 studies comprising 15 828 spontaneous ICH patients (mean age, 64.8 years; men, 60.8%). The pooled prevalences of hypertensive arteriopathy ICH, undetermined ICH, and cerebral amyloid angiopathy ICH were 50% (95% CI, 43%–58%), 18% (95% CI, 13%–23%), and 12% (95% CI, 7%–17% [P<0.001 between subgroups]). The volume of ICH was the largest in cerebral amyloid angiopathy ICH (24.7 [95% CI, 19.7–29.8] mL), followed by hypertensive arteriopathy ICH (16.2 [95% CI, 10.9–21.5] mL) and undetermined ICH (15.4 [95% CI, 6.2–24.5] mL). Among patients with undetermined ICH, the rates of short-term mortality (within 3 months) and concomitant intraventricular hemorrhage were 33% (95% CI, 25%–42%) and 38% (95% CI, 28%–48%), respectively. Subgroup analysis demonstrated a higher rate of undetermined ICH among studies that did not use an etiology-oriented classification (22% [95% CI, 15%–29%]). No difference was observed between studies based on the completion of detailed neuroimaging to assess the rates of undetermined ICH (P=0.62).

Conclusions:

The etiology of spontaneous ICH remains unknown or cryptogenic among 1 in 7 patients in studies using etiology-oriented classification and among 1 in 4 patients in studies that avoid using etiology-oriented classification. The short-term mortality in undetermined ICH is high despite the relatively small ICH volume.

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FIP1L1-PDGFRA-Associated Hypereosinophilic Syndrome as a Treatable Cause of Watershed Infarction

In case you have a cryptogenic stroke of unexplained origin you can have your doctor check this out.

FIP1L1-PDGFRA-Associated Hypereosinophilic Syndrome as a Treatable Cause of Watershed Infarction

Juliette Tennenbaum

,

Matthieu Groh

,

Laura Venditti

,

France Campos-Gazeau

,

Emilie Chalayer

,

Thomas De Broucker

,

Mohamed Hamidou

,

Mathilde Hunault

,

Aicha Lyoubi

… See all authors

Originally published26 Jul 2021https://doi.org/10.1161/STROKEAHA.121.034191Stroke. ;0:STROKEAHA.121.034191

Abstract

Background and Purpose:

Ischemic stroke has been reported in various conditions associated with eosinophilia. FIP1L1-PDGFRA fusion ([Fip1-like 1-platelet-derived growth factor receptor alpha]; F/P) leads to the proliferation of the eosinophilic lineage and thus to a clonal hypereosinophilic syndrome that is highly responsive to imatinib.

Methods:

We previously reported on a nationwide retrospective study of 151 patients with F/P-associated clonal hypereosinophilic syndrome. Patients from this cohort with a clinical history of ischemic stroke (as well as 2 additional cases) were further analyzed to better define their clinical picture and outcomes.

Results:

Sixteen male patients (median age, 51 [43–59] years) with low-to-intermediate cardiovascular risk were included. Median National Institutes of Health Stroke Scale was 4 (range, 1–6). Most cerebral imaging disclosed multiple bilateral infarctions of watershed distribution (69%). Despite frequent cardiac involvement (50%), cardiac thrombus was evidenced in a single patient and, according to the TOAST classification (Trial of ORG 10172 in Acute Stroke Treatment), 62.5% of strokes were presumably of undetermined etiology. Among the 15 patients treated with imatinib, and after a median follow-up of 4.5 years, stroke recurred in only 3 patients (consisting of either cardio embolic or hemorrhagic events, unrelated to the first episode).

Conclusions:

F/P+ clonal hypereosinophilic syndrome is a diagnosis to consider in patients with unexplained ischemic stroke and hypereosinophilia (especially in the setting of multiple cortical borderzone distribution) and warrants prompt initiation of imatinib.

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• Download PowerPoint

 

 

Loop Recorder Proves Mettle in Broader Stroke Population

This sounds extremely promising for creation of a protocol. WHOM is going to do that?(Specific names only, otherwise it will never get done.)

Loop Recorder Proves Mettle in Broader Stroke Population

STROKE AF trial supports use outside of cryptogenic stroke category

by Crystal Phend, Senior Editor, MedPage Today March 18, 2021

Among patients with ischemic stroke attributed to large artery atherosclerosis or small vessel occlusion, atrial fibrillation (Afib) detection was increased more than seven-fold with an implantable cardiac monitor (ICM) compared with standard care, according to the STROKE AF trial.

After 1 year, the Reveal LINQ device picked up previously unidentified Afib in 12.1% of patients, while usual care identified just 1.8% (HR 7.41, 95% CI 2.60-21.28, P<0.001), reported Lee H. Schwamm, MD, of Massachusetts General Hospital in Boston, at the American Stroke Association's virtual International Stroke Conference.

The findings of non-cardioembolic stroke of presumed known origin tracked almost exactly with those seen previously in the CRYSTAL AF trial, which established loop recorder use in cryptogenic strokes, said Schwamm.

"Forget about the first stroke," he told MedPage Today. "If you find fibrillation, you should treat it. ... The reality is it sort of doesn't matter what provoked it, other than direct manipulation of the heart during heart surgery."

The real question, he said, is "should we start monitoring anybody with a stroke or a sufficiently elevated CHADS VASC score to try to detect undetected atrial fibrillation? Because it will change how we try to prevent their stroke."

That makes this an important study, commented Louise McCullough, MD, PhD, of the University of Texas Health Science Center at Houston.

"Every time we send somebody with a stroke, either with large vessel atherosclerosis or small vessel disease, out on antiplatelets, we feel like we're protecting them," she said. "But if they have occult Afib, we're not."

Such patients who initially appear to be in sinus rhythm typically haven't been considered for extended rhythm monitoring, she noted.

"Even if you prevent a few cardioembolic strokes, that's a huge cost savings for public health," she said. "We need to catch these people; we need to have a very low bar and a high index of suspicion. This study shows it needs to be even higher than we had previously thought."

Notably, median time to the first Afib episode in STROKE AF with the device was 99 days, and 78% would have been missed with 30-day monitoring, suggesting that a patch or Holter monitor wouldn't catch many of these cases.

The number needed to monitor to detect one case of Afib was just eight in the ICM group, compared with 56 in the standard-of-care group.

The open-label trial included 496 patients with ischemic stroke attributed to small vessel occlusion or cervical or intracranial artery atherosclerosis treated at 33 U.S. centers. The population was an elevated-risk group: patients who weren't at least 60 years old could be enrolled as young as 50 only if they had a documented medical history of at least one additional stroke risk factor (congestive heart failure, hypertension, diabetes, second stroke more than 90 days prior, or vascular disease).

Participants were randomized within 10 days of the index stroke to the continuous monitoring arm with the Reveal LINQ ICM or to whatever the site-specific standard of care was for arrhythmia detection.

Afib had to last for at least 30 seconds (although the ICM only picked up episodes of at least 2 minutes' duration) without detectable P waves and be adjudicated by a clinical events committee.

For 55% of the patients with Afib, the duration of the longest detected episode was an hour or more, which "would be considered by many physicians appropriate to treat with anticoagulation for secondary prevention," Schwamm told the virtual session attendees.

Indeed, 18 of the 27 Afib patients (66.7%) in the ICM group were started on an oral anticoagulant compared with three of the four patients identified with usual care (75%).

While the trial was underpowered for such clinical endpoints, there were numerically fewer recurrent strokes in the ICM group at 12 months (15 vs 23 patients in the usual care group).

"Our long-term results (36 months) and other ongoing studies may shed light on the clinical significance of ICM-detected [Afib] for stroke recurrence," Schwamm noted in the presentation.

• 

  Crystal Phend focuses on cardiology as an associate editor at MedPage Today. Follow

Disclosures

The study was funded by Medtronic.

Schwamm disclosed relationships with Medtronic, the Massachusetts Department of Public Health, Penumbra, Diffusion Pharma, and the NINDS StrokeNet Network.

Primary Source

International Stroke Conference

Source Reference: Schwamm LH, et al "STROKE AF: atrial fibrillation in non-cardioembolic stroke of presumed known origin" ISC 2021; Abstract LB6.

 

Cardiac monitor insertion after cryptogenic stroke may be cost-effective in US

 Now this needs to be written up as a protocol and distributed to all stroke hospitals in the US. Whom in your stroke hospital is the contact person for this who then distributes it to all staff? Don't have such a person, then the board of directors needs to be fired.

Cardiac monitor insertion after cryptogenic stroke may be cost-effective in US

Immediate insertion of a cardiac monitor following first cryptogenic stroke was cost-effective in the U.S. compared with delayed implantation after 30-day Holter monitoring, according to a study.

In the study published in the Journal of Comparative Effectiveness Research, detection of atrial fibrillation with an insertable cardiac monitor (Reveal XT, Medtronic) after a stroke of indeterminate source, although more expensive upfront, was more cost-effective compared with delayed implantation or standard care due to the odds of detecting AF within 30 days of stroke.

Source: Adobe Stock

“The challenge for devices is to show cost-effectiveness data over a prolonged period of time in a population of patients so that you know that your investment at baseline pays off over the course of time and pays back if you like,” Klaus Witte, MD, FRCP, FESC, FACC, senior lecturer and consultant cardiologist at the Leeds Institute for Cardiovascular and Metabolic Medicine at the University of Leeds, U.K., told Healio. “The other thing is that everything we do is slightly more expensive. People always say, ‘If you get the population healthy, you will save money.’ That is wrong. If you get the population healthy, they will live longer and end up costing more money in due course. So, health economics and cost-effectiveness analysis are important because there are so many pressures on health care services to know the best places to invest our money.”

For this analysis, researchers modeled lifetime costs and quality-adjusted life-years for three cardiac monitoring strategies after cryptogenic stroke. These strategies included cardiac monitor insertion immediately after cryptogenic stroke; delayed insertion after Holter monitoring; and standard care with intermittent ECG and Holter monitoring. Patient characteristics and detection efficacy were based on data from the CRYSTAL-AF trial.

Klaus Witte

“The implantable cardiac monitor is a little device that you stick under the skin and it’s a very small procedure. However, there is this slight hesitancy by some of my colleagues to try and delay it or avoid it altogether, partly because of the upfront cost and partly because it is an invasive procedure and many of them are stroke physicians, so they’re not familiar with putting in monitors,” Witte told Healio.

“There’s this trend that has occurred where physicians choose to do monitoring before they put in the devices,” Witte said in an interview. “Maybe with a 30-day monitor, there is a small likelihood of identification of atrial fibrillation in those patients. But if you take 100 people, and stick a patch on all of them, you have had to pay for that patch in 100 people, knowing that it will only identify a tiny proportion of those patients that would have been identified with the loop recorder. But at the end of 30 days, you still have to put the loop recorder into the other remaining patients because you haven’t excluded AF in them, you just haven’t found it yet.”

Researchers found that the immediate use of an insertable cardiac monitor, compared with standard care, showed an incremental benefit of 0.198 QALYs and 0.226 life-years, a reduction of 60 strokes per 1,000 patients and an incremental cost of $6,211. According to the study, these benefits were driven by the 3 years of insertable cardiac monitoring before removal due to the device meeting its battery life expectancy.

The strategy of immediate cardiac monitor implantation after stroke of unknown origin was also associated with lower stroke event costs and lower long-term health-related costs, according to the study.

Compared with standard care, immediate cardiac monitor insertion demonstrated an incremental cost‐effectiveness ratio (ICER) of $31,345 per QALY and $27,438 per life-year gained.

Compared with delayed insertion after Holter monitoring, the strategy of immediate cardiac monitor insertion after cryptogenic stroke was associated with an additional 0.001 QALYs and cost, on average, $135 less over a patient’s lifetime.

Moreover, for patients who underwent delayed cardiac monitor implantation, the 7-day costs totaled $233,300 per 1,000 patients and detected just 3% of patients who were ultimately diagnosed with AF.

“One of the things that I wanted to do as part of this research was to model it if we follow the less invasive doctor’s trend of doing some monitoring first, before we allocate them all to the loop recorder,” Witte told Healio. “If you do that, you end up paying a huge amount of money for however many patches, knowing that 80% or more are going to need a loop recorder anyway.

“It was inferior in terms of cost-effectiveness. It was more expensive to do that for a given outcome because you’ve got to pay for all of the monitors and you lose very few of the loop recorders after the 30 days,” Witte said in an interview. “In other words, you avoid a loop recorder in very few patients. It is a common misconception that we can avoid putting a loop recorder in if we monitor people for a month beforehand. A vast majority of patients will need a loop recorder eventually, so you should jolly well get on and do it early.”

In a subgroup analysis of higher-risk patients, the ICER was higher in patients with CHADS₂ scores of 2 ($53,492 ) and 3 ($38,415) compared with the entire cohort ($31,345). Among patients with CHADS₂ scores of 4 to 6, the ICER decreased to $19,514 per QALY gained, according to the study.

“The primary take-home message for clinicians is the same message that I would make for payers in society,” Witte told Healio. “The upfront investment of a loop recorder in somebody who’s had a stroke makes sense because you are putting a good process in place that will identify future risk, allowing you to intervene before the second stroke occurs with a very well-proven intervention, namely anticoagulation for atrial fibrillation. Given that around 30% of people with this type of stroke go on to have atrial fibrillation, whether it’s permanent or intermittent, the benefits of anticoagulation are proven.”