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Enhanced, prolonged monitoring increases AF detection in patients with stroke
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Prolonged and enhanced monitoring by means of repeated 10-day Holter monitoring initiated early after ischemic stroke was more effective than standard care for the detection of atrial fibrillation within the first 6 months, according to data presented at the International Stroke Conference.
Enhanced and prolonged Holter monitoring “should be considered for all stroke patients in whom the detection of AF is of therapeutic relevance,” Rolf Wachter, MD, head senior physician, Clinic for Cardiology and Pneumology, University of Göttingen, Germany, said during a press conference.
Rolf Wachter
The prospective, randomized, controlled Finding Atrial Fibrillation in Stroke Patients Trial included participants aged 60 years and older with ischemic stroke within 7 days of symptom onset, sinus rhythm on admission and no evidence of hemorrhagic stroke, AF or severe carotid artery stenosis. The patients were randomly assigned to receive enhanced and prolonged rhythm monitoring via repeated 10-day Holter with analysis in a dedicated core laboratory (n = 200) or to standard care with a recommendation of at least 24 hours of monitoring (n = 198) at the time of stroke and 3 and 6 months later. The device used in the intervention group was the CardioMem 3000 (Getemed), and alternative thumb-sensor monitoring (Zenicor) was offered to patients unwilling to repeat the Holter after 3 or 6 months.
The cohort had a mean age of 73 years, 40% were women and the median time from symptom onset to randomization was 3 days. The study was conducted at four centers in Germany between May 2013 and Aug. 31, 2014.
The primary endpoint was newly detected AF, lasting 30 seconds or longer, within 6 months and before stroke recurrence. This occurred in 13.5% of the intervention group vs. 4.5% of the standard-care group (P = .002). After 12 months, incident AF or flutter was detected in 13.5% of the intervention group vs. 6.1% of the standard-care group (P = .02).
A secondary endpoint of recurrent stroke after 12 months was detected in 2.5% of the intervention group vs. 4.5% of the standard-care group (P = .28). In other results, the rate of all-cause death after 12 months was 3% vs. 4.5% (P = .45), respectively, and the rate of transient ischemic attack after 12 months was 1.5% vs. 2.5% (P = .48), respectively.
All patients with newly diagnosed AF in both arms of the trial received oral anticoagulation, and 97% maintained anticoagulation at 12-month follow-up. At each follow-up visit — 3, 6 and 12 months — rates of anticoagulation for atrial fibrillation were higher in the intervention group than the standard-care group.
During the press conference, Wachter discussed some limitations of this study. The trial was performed only in Germany, which has a predominantly white population, and the participation rate for enhanced and prolonged Holter monitoring decreased over time, he said. – by Tracey Romero
Reference:
Wachter R. LB 2. Presented at: International Stroke Conference; Feb. 16-19, 2016; Los Angeles.
Disclosures: The trial was funded by Boehringer Ingelheim. Wachter reports receiving a research grant from Boehringer Ingelheim and speaker fees from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb/Pfizer and Daiichi Sankyo.
Perspective
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Philip B. Gorelick, MD, MPH
The number of heart rhythm monitoring studies that have gone beyond several days are all showing similar findings: the longer you monitor, the more AF that you will detect. These findings are along the same lines as CRYSTAL AF and other similar studies showing that you have to monitor anywhere from about several months up to 160 days to begin to detect AF.
The Finding Atrial Fibrillation in Stroke Patients Trial enforces our practice of recommending monitoring for AF when there is cryptogenic stroke or a stroke of undetermined cause. This study adds more data to our existent practice guidance on AF monitoring.
This was a well-done, thoughtful study that is very much in step with what we have been noting in some of the other studies. Furthermore, the study shows that there is a different way you can do things: prolonged Holter monitoring rather than shorter Holter monitoring, which is commonly done for 24, 48 or 72 hours.
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