3-Year Data from STROKE-AF Underscores Ability of ICM in Stroke Patients

Does your doctor and hospital have a protocol on this to prevent your next stroke? NO? Then you don't have a functioning stroke doctor or hospital. Why the fuck are you there? 

3-Year Data from STROKE-AF Underscores Ability of ICM in Stroke Patients

New data from a predefined secondary analysis of the STROKE-AF trial provides insight into the 3-year incidence of atrial fibrillation among patients with a history of ischemic stroke caused by atherosclerosis.

Lee Schwamm, MD

Data from the 3-year follow-up of the STROKE-AF trial presented at American Stroke Association’s International Stroke Conference (ISC) 2023 is underlining the importance of long-term monitoring and use of insertable cardiac monitors (ICMs) for arrhythmias in patients with a history of ischemic stroke.

Results of the secondary analysis, which compared detection of arrhythmia with ICM against standard of care, suggest more than 20% of patients with ischemic stroke attributed to small or large vessel disease had atrial fibrillation (AF), with the detection rate 10 times greater using ICM than with standard of care.¹

“We found that the rate of atrial fibrillation continued to increase over the course of the three years, therefore, it’s not just a short-lived event and self-resolving related to the initial stroke,” said Lee Schwamm, MD, a professor of neurology at Harvard Medical School in Boston.² “Fibrillation is common in these patients. Relying on routine monitoring strategies is not sufficient and neither is placing a 30-day continuous monitor on the patient. Even if fibrillation is ruled out in the first 30 days, most of the cases are missed — because, as we found, more than 80% of the episodes are first detected more than 30 days after the stroke.”

A prospective, randomized, controlled, multicenter trial STROKE-AF randomized 492 patients in a 1:1 ration to ICM insertion within 10 days of the index stroke or standard of care, which was defined as site-specific usual care consisting of external cardiac monitoring.³ As part of the study protocol, patients included in the trial were 60 years of age or older or 50-59 years with an additional stroke risk factors and no contraindication to long-term oral anticoagulation.

The 12-month results of the STROKE-AF trial indicated use of ICM was associated with a significantly increased rate of AF detection compared with standard of care (hazard ratio [HR], 7.4 [95% CI, 2.6-21.3]; P <.001).³ A predefined secondary analysis of the trial, the current study, which was funded by Medtronic, was designed as an analysis of AF incidence up to 3 years following index event.¹

Upon analysis, the 3-year incidence rates of AF were 21.7% in the ICM arm and 2.4% in the standard of care (hazard ratio [HR], 10.0 [95% CI, 4.0-25.2]; P <.001), with investigators reporting no significant differences between stroke subtypes. Among those in the ICM arm who experienced AF, the median duration of their longest episode was 10.0 (interquartile range [IQR], 4.0-192.0) minutes, with investigators pointed out 37.2% of patients experiencing an episode lasting at least an hour. In further subgroup analyses, results indicated the median maximum daily AF burden in those AF burden was 0.3 hours, with 25% having AF longer than 5.3 hours. Investigators pointed out there was no significant differences in rates of recurrent stroke between the ICM (17.0%) and the standard of care (14.1%) at 3 years (HR, 1.10 [95% CI, 0.67-1.78]; P=.71).¹

“There is still a lot that we don’t yet understand about why people who have had a previous stroke have another one; however, this study contributes important information to one potential cause— namely, unsuspected atrial fibrillation—for some of those 25% of patients with recurrent strokes,” Schwamm added.² “These patients are at increased risk of recurrent strokes due to their known cardiovascular risk factors, such as hypertension and elevated cholesterol and blood pressure. What we need to sort out is what additional risk does atrial fibrillation add, and can the use of anticoagulation reduce that risk, especially for the type of major and disabling strokes that are often associated with atrial fibrillation.”

References

1. Schwamm L. International Stroke Conference 2023. In: Dallas, TX; 2023.
2. Irregular heart rhythms detected in 1 in 5 stroke survivors, increasing risk of new stroke. American Heart Association Newsroom. February 2023. https://newsroom.heart.org/news/irregular-heart-rhythms-detected-in-1-in-5-stroke-survivors-increasing-risk-of-new-stroke. Accessed February 13, 2023.
3. Bernstein RA, Kamel H, Granger CB, et al. Effect of Long-term Continuous Cardiac Monitoring vs Usual Care on Detection of Atrial Fibrillation in Patients With Stroke Attributed to Large- or Small-Vessel Disease: The STROKE-AF Randomized Clinical Trial. JAMA. 2021;325(21):2169–2177. doi:10.1001/jama.2021.6470

Insertable Cardiac Monitor Detects ‘Silent’ Atrial Fibrillation in High-Risk Patients:

Something to discuss with your doctor. I bet this is better than the apps available on your smartphone.
http://dgnews.docguide.com/insertable-cardiac-monitor-detects-silent-atrial-fibrillation-high-risk-patients?

May 16, 2017

By Louise Gagnon
CHICAGO -- May 16, 2017 -- The use of an insertable cardiac monitor (ICM) was effective in detecting “silent” atrial fibrillation (AF) in patients at high risk for AF and stroke, according to a study presented here at the 38th Annual Scientific Sessions of the Heart Rhythm Society (HRS).
“Atrial fibrillation unknown by patients or physicians is not uncommon,” said James A. Reiffel, MD, Division of Cardiology, Columbia University, and New York Presbyterian Hospital, New York, New York. “Patients can have AF without having symptoms, so they do not present themselves [to physicians]. There are a significant number of strokes that present without a prior history of AF. Lo and behold, you evaluate patients and find out that they have AF.”
The prospective, single-arm, multicentre study evaluated the presence and quantified the incidence of AF lasting at least 6 minutes in patients with unrecognised AF but at high risk for AF, such as patients with heart failure, hypertension, diabetes, and vascular disease.
The main outcome from the study was detection of AF at 18 months with secondary outcomes being detection rates from 30 days to 30 months. The researchers also looked at detection rates stratified by patients CHADS2 scores.
A total of 385 patients received an ICM and were followed for 22.5 months. The AF detection rate at 18 months was 29.3% with the rate as high as 40.0% at 30 months.
“The yield of the device is impressive,” said Dr. Reiffel, noting that 30 days of monitoring is often not sufficient to detect AF.
The AF detection rate did not differ by CHADS2 scores (P = .23). The median time from the time of insertion of the ICM to identification of the first AF episode was 123 days.
The technology was extremely well-tolerated, and its use did not produce any adverse events, said Dr. Reiffel.
More than half of the patients were prescribed oral anticoagulants after the identification of AF to reduce the risk of stroke.
Funding for this study was provided by Medtronic, Inc.
[Presentation title: High Incidence of Previously Unknown (Silent) Atrial Fibrillation in Patients at High Risk for Atrial Fibrillation and Stroke: Primary Results From the REVEAL-AF study. Abstract C-LBCT02-05]