Implantable ECG improves AF detection in patients with ischemic stroke
Click Here to Manage Email Alerts
In patients with ischemic stroke and no prior evidence of atrial fibrillation, implantable ECG monitoring for 12 months detected AF more often than external monitoring for 30 days, according to the results of the PER DIEM trial.
The researchers randomly assigned 300 patients with ischemic stroke but no confirmed AF (median age, 64 years; 40% women; median CHA2DS2-VASc score, 4) to receive a long-term implantable loop recorder (Reveal LINQ, Medtronic) plus remote monitoring (MyCareLink, Medtronic) or an external event-triggered loop recorder (Spiderflash-t, Sorin).
The primary outcome of definite or highly probable AF, defined as adjudicated AF episodes lasting at least 2 minutes, at 12 months occurred in 15.3% of the implantable group and 4.7% of the external group (between-group difference, 10.7 percentage points; 95% CI, 4-17.3; RR = 3.29; 95% CI, 1.45-7.42; P = .003), Brian H. Buck, MD, MSc, associate professor of neurology at the University of Alberta in Edmonton, Canada, and colleagues wrote in JAMA.
The secondary outcome of time to first AF episode lasting at least 2 minutes was lower in the implantable group compared with the external group (adjusted HR = 3.36; 95% CI, 1.44-7.84; P = .005; log-rank P = .002), and the secondary outcome of death or AF detection at 12 months occurred more frequently in the implantable group (17.3% vs. 6.7%; between-group difference, 10.7 percentage points; 95% CI, 3.4-17.9; P = .007; aHR = 2.64; 95% CI, 1.27-5.29; P = .009), according to the researchers.
There was no difference between the groups in the secondary outcomes of transient ischemic attack, recurrent ischemic stroke, intracerebral hemorrhage or death, Buck and colleagues wrote.
One device-related serious adverse event occurred in the implantable group and none occurred in the external group.
All AF diagnoses resulted in prescriptions for oral anticoagulation, the researchers wrote.
“Longer-term cardiac monitoring of all patients with stroke and without proven AF would have cost implications,” Buck and colleagues wrote. “The implantable loop recorders used in this study are single-use devices. Although the PER DIEM trial found a relatively low number needed to monitor to detect AF, it remains unproven whether more widespread adoption of an implantable loop recorder will translate into lower stroke rates and health economic benefits. ... Studies are needed to determine if there are subgroups of stroke patients in whom empirical anticoagulation therapy is more cost-effective than extended cardiac monitoring strategies.”
Perspective
Back to Top
Jonathan P. Piccini, MD, MHS, FACC, FAHA, FHRS
PER DIEM is yet another study that confirms and extends prior observations that continuous monitoring with an implanted loop monitor yields greater arrhythmia detection than ambulatory monitoring. The results echo findings from other studies like CRYSTAL AF and STROKE AF. As the authors note, a key question will be if the use of an implantable loop recorder leads to improved CV outcomes and if it is economically attractive (cost-effective).
Implantable loop recorders already are becoming more common in clinical practice. These results will probably amplify/augment that trend further.
The knowledge gaps that remain are whether the recorders improve hard CV outcomes, whether they are cost-effective and whether they are still going to be relevant when everyone is wearing next-generation watches that can actively screen for arrhythmias with high sensitivity and specificity.
Collapse
Click Here to Manage Email Alerts