Vol 53, No 3 (2019)
Review Article
Published online: 2019-05-28
Statement by a Working Group conceived by the Polish National Consultants in Cardiology and Neurology addressing the use of implantable cardiac monitors in patients after ischaemic embolic stroke of undetermined source
1
, 2, 3, 4, 5, 6, 2, 7, 8, 1
, 2, 3, 4, 5, 6, 2, 7, 8, 1
Abstract
Introduction. Stroke remains one of the main causes of death and the most common cause of long-term disability in adults. Embolic strokes of undetermined source (ESUS) amount to a significant proportion of all ischaemic strokes. Detection of atrial fibrillation (AF) in this group of patients would allow for a major therapeutic decision to switch from antiplatelets to oral anticoagulants and therefore significantly reduce the risk of recurrence.
State of the Art. Current technology allows long-term continuous ECG monitoring with different systems, including implantable cardiac monitors (ICM). However, in Poland lack of reimbursement does not allow their use in everyday clinical practice.
Clinical Implications. This is a statement by a Working Group conceived by the Polish National Consultants in Cardiology and Neurology addressing the use of ICM in patients after ischaemic embolic strokes of undetermined source. The aim was to develop reasonable and comprehensive guidance on how to select and manage candidates for ICM in order to obtain the maximum benefit for Polish public health.
Future Directions. This expert opinion is not intended as a guideline but it provides advice as to how to optimise the potential use of ICM in patients after ESUS in the Polish setting.
Keywords: acute ischaemic strokeembolic stroke of undetermined sourceatrial fibrillationECG monitoring
References
- Kim AS, Cahill E, Cheng NT. Global Stroke Belt: Geographic Variation in Stroke Burden Worldwide. Stroke. 2015; 46(12): 3564–3570.
- Krishnamurthi RV, Feigin VL, Forouzanfar MH, et al. Global Burden of Diseases, Injuries, Risk Factors Study 2010 (GBD 2010), GBD Stroke Experts Group. Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet Glob Health. 2013; 1(5): e259–e281.
- Mapa potrzeb zdrowotnych w zakresie lecznictwa szpitalnego dla Polski. Ministerstwo Zdrowia 2018. http://www.mpz.mz.gov. pl/mapy-szpitalne-ustawowe-2018/, dostęp 06. ; 12: 2018.
- Adams HP, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993; 24(1): 35–41.
- Hart RG, Diener HC, Coutts SB, et al. Cryptogenic Stroke/ESUS International Working Group. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. 2014; 13(4): 429–438.
- Bembenek JP, Karlinski MA, Kurkowska-Jastrzebska I, et al. Embolic strokes of undetermined source in a cohort of Polish stroke patients. Neurol Sci. 2018; 39(6): 1041–1047.
- Li L, Yiin GS, Geraghty OC, et al. Oxford Vascular Study. Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient ischaemic attack and ischaemic stroke: a population-based study. Lancet Neurol. 2015; 14(9): 903–913.
- Hart R, Pearce L. Antithrombotic Therapy To Prevent Stroke in Patients with Atrial Fibrillation. Annals of Internal Medicine. 2000; 132(10): 841.
- Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014; 383(9921): 955–962.
- López-López JA, Sterne JAC, Thom HHZ, et al. Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess. 2017; 21(9): 1–386.
- Hellwig S, Grittner U, Audebert H, et al. Non-vitamin K-dependent oral anticoagulants have a positive impact on ischaemic stroke severity in patients with atrial fibrillation. Europace. 2018; 20(4): 569–574.
- Boulanger JM, Lindsay MP, Gubitz G, et al. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. Int J Stroke. 2018; 13(9): 949–984.
- Kirchhof P, Benussi S, Kotecha D, et al. ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016; 37(38): 2893–2962.
- Hart RG, Catanese L, Perera KS, et al. Embolic Stroke of Undetermined Source: A Systematic Review and Clinical Update. Stroke. 2017; 48(4): 867–872.
- Diener HC, Easton JD, Granger CB, et al. RE-SPECT ESUS Investigators. Design of Randomized, double-blind, Evaluation in secondary Stroke Prevention comparing the EfficaCy and safety of the oral Thrombin inhibitor dabigatran etexilate vs. acetylsalicylic acid in patients with Embolic Stroke of Undetermined Source (RE-SPECT ESUS). Int J Stroke. 2015; 10(8): 1309–1312.
- Hart RG, Sharma M, Mundl H, et al. NAVIGATE ESUS Investigators. Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source. N Engl J Med. 2018; 378(23): 2191–2201.
- Carmona-Puerta R, Castro-Torres Y. Atrial fibrillation and cryptogenic stroke. What is the current evidence? Role of electrocardiographic monitoring. J Arrhythm. 2018; 34(1): 1–3.
- Haeusler KG, Gröschel K, Köhrmann M, et al. Expert opinion paper on atrial fibrillation detection after ischemic stroke. Clin Res Cardiol. 2018; 107(10): 871–880.
- Haeusler KG, Tütüncü S, Schnabel RB. Detection of Atrial Fibrillation in Cryptogenic Stroke. Curr Neurol Neurosci Rep. 2018; 18(10): 66.
- Sanna T, Ziegler P, Crea F. Detection and management of atrial fibrillation after cryptogenic stroke or embolic stroke of undetermined source. Clinical Cardiology. 2018; 41(3): 426–432.
- Widimsky P, Doehner W, Diener HC, et al. ESC Council on Stroke. The role of cardiologists in stroke prevention and treatment: position paper of the European Society of Cardiology Council on Stroke. Eur Heart J. 2018; 39(17): 1567–1573.
- Jonas D, Kahwati L, Yun J, et al. Screening for Atrial Fibrillation With Electrocardiography. JAMA. 2018; 320(5): 485.
- Chou PS, Ho BL, Chan YH, et al. Delayed diagnosis of atrial fibrillation after first-ever stroke increases recurrent stroke risk: a 5-year nationwide follow-up study. Intern Med J. 2018; 48(6): 661–667.
- Powers WJ, Rabinstein AA, Ackerson T, et al. American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018; 49(3): e46–e4e110.
- Grupa Ekspertów Sekcji Chorób naczyniowych Polskiego Towarzystwa Neurologicznego. Postępowanie w udarze mózgu. Neurol Neurochir Pol. 2012; 46: s1–116.
- Steffel J, Verhamme P, Potpara TS, et al. ESC Scientific Document Group, ESC Scientific Document Group . The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018; 39(16): 1330–1393.
- Mairesse GH, Moran P, Van Gelder IC, et al. ESC Scientific Document Group. Screening for atrial fibrillation: a European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLAECE). Europace. 2017; 19(10): 1589–1623.
- Brachmann J, Morillo CA, Sanna T, et al. Uncovering Atrial Fibrillation Beyond Short-Term Monitoring in Cryptogenic Stroke Patients: Three-Year Results From the Cryptogenic Stroke and Underlying Atrial Fibrillation Trial. Circ Arrhythm Electrophysiol. 2016; 9(1): e003333.
- Sanna T, Diener HC, Passman RS, et al. CRYSTAL AF Investigators. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014; 370(26): 2478–2486.
- Ritter M, Kochhäuser S, Duning T, et al. Occult Atrial Fibrillation in Cryptogenic Stroke. Stroke. 2013; 44(5): 1449–1452.
- Muscari A, Bonfiglioli A, Faccioli L, et al. Usefulness of the MrWALLETS Scoring System to Predict First Diagnosed Atrial Fibrillation in Patients With Ischemic Stroke. Am J Cardiol. 2017; 119(7): 1023–1029.
- Kwong C, Ling AY, Crawford MH, et al. A Clinical Score for Predicting Atrial Fibrillation in Patients with Cryptogenic Stroke or Transient Ischemic Attack. Cardiology. 2017; 138(3): 133–140.
- Ricci B, Chang AD, Hemendinger M, et al. A Simple Score That Predicts Paroxysmal Atrial Fibrillation on Outpatient Cardiac Monitoring after Embolic Stroke of Unknown Source. J Stroke Cerebrovasc Dis. 2018; 27(6): 1692–1696.
- Orlov MV, Ghali JK, Araghi-Niknam M, et al. Atrial High Rate Trial Investigators. Asymptomatic atrial fibrillation in pacemaker recipients: incidence, progression, and determinants based on the atrial high rate trial. Pacing Clin Electrophysiol. 2007; 30(3): 404–411.
- Strickberger SA, Ip J, Saksena S, et al. Relationship between atrial tachyarrhythmias and symptoms. Heart Rhythm. 2005; 2(2): 125–131.
- Choe WC, Passman RS, Brachmann J, et al. CRYSTAL AF Investigators. A Comparison of Atrial Fibrillation Monitoring Strategies After Cryptogenic Stroke (from the Cryptogenic Stroke and Underlying AF Trial). Am J Cardiol. 2015; 116(6): 889–893.
- Pürerfellner H, Sanders P, Sarkar S, et al. Adapting detection sensitivity based on evidence of irregular sinus arrhythmia to improve atrial fibrillation detection in insertable cardiac monitors. Europace. 2018; 20(FI_3): f321–f328.
