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Incidence and Predictive Factors of Hidden Atrial Fibrillation Detected by Implantable Loop Recorder After an Embolic Stroke of Undetermined Source.

ABSTRACT: Background:The term embolic stroke of undetermined source (ESUS) has been defined for patients with ischemic strokes, where neither a cardioembolic nor a non-cardiac source can be detected. These patients may have asymptomatic episodes of atrial fibrillation (AF). Prolonged monitoring with implantable loop recorder (ILR) and daily remote interrogation in patients after an ESUS has shown an incidence of AF of about 25%. Aims:The main objective of this study was to analyze the incidence and predictive factors of atrial fibrillation in patients with ESUS who underwent an ILR implantation. Methods:It was a single center study. From June 2013 to January 2017 all consecutive patients with an ESUS, who underwent an ILR implantation searching for hidden AF, were included. Possible predictive factors of AF were also analyzed. Results:65 patients were included (mean age 65.4±13.8 years, 55.4% males, mean CHA2DS2VASc score 2.3± 1.5). After a median follow-up of 17.1±10.7 months, AF was detected in 19 (29.2%) of patients. Variables associated with AF were: age > 65 years (HR 9.45 (CI 95% 1.25-71.34); p= 0.02), CHA2DS2VASC score?2 (HR 4.09 (CI 95% 0.93-17.87); p=0,06), left atrial enlargement (HR 2.29 (CI 95% 0.89-5.91); p=0.08) and presence of Supraventricular premature complex(SVC) on 24-hour Holter (HR 4.05 (CI 95% 1.55-10.57); p = 0.004) A cut-point of 0.15% for SVC was identified to predict AF with a sensitivity and specificity of 88.9 and 90%, respectively. A CHA2DS2VASc score<2 and age<65 years showed a negative predictive value to exclude AF of 91.3% and 96%, respectively. Conclusion:A high incidence of AF was detected in this population. Age >65 years, LA enlargement, CHA2DS2VASC score?2 and presence of SVC on 24-hour Holter are predictive factors of AF in patients with ESUS.

SUBMITTER: Victor CU

PROVIDER: S-EPMC6533811 | biostudies-literature | 2018 Oct-Nov

REPOSITORIES: biostudies-literature

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Incidence and Predictive Factors of Hidden Atrial Fibrillation Detected by Implantable Loop Recorder After an Embolic Stroke of Undetermined Source.

Víctor Castro Urda CU Carolina Parra Esteban PE Jorge Toquero Ramos TR Joaquín Carneado-Ruiz CR Manuel Sánchez García SG Marta Cobo Marcos CM José María Fernández Villanueva FV Chinh Pham Trung PT Javier Ortega Marcos OM Susana Mingo Santos MS Sánchez Diego Jiménez J Carlos Jiménez Ortiz JO Ignacio Fernández Lozano FL

Journal of atrial fibrillation 20181031 3

<h4>Background</h4>The term embolic stroke of undetermined source (ESUS) has been defined for patients with ischemic strokes, where neither a cardioembolic nor a non-cardiac source can be detected. These patients may have asymptomatic episodes of atrial fibrillation (AF). Prolonged monitoring with implantable loop recorder (ILR) and daily remote interrogation in patients after an ESUS has shown an incidence of AF of about 25%.<h4>Aims</h4>The main objective of this study was to analyze the incid ...[more]

PMID: 31139276

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Project description:ObjectivePrevention of recurrent stroke in patients with embolic stroke of undetermined source (ESUS) is challenging. The advent of safer anticoagulation in the form of direct oral anticoagulants (DOACs) has prompted exploration of prophylactic anticoagulation for all ESUS patients, rather than anticoagulating just those with documented atrial fibrillation (AF). However, recent trials have failed to demonstrate a clinical benefit, while observing increased bleeding. We modeled the economic impact of anticoagulating ESUS patients without documented AF across multiple geographies.MethodsCRYSTAL-AF trial data were used to assess ischaemic stroke event rates in ESUS patients confirmed AF-free after long-term monitoring. Anticipated bleeding event rates (including both minor and major bleeds) with aspirin, dabigatran 150 mg, and rivaroxaban 20 mg were sourced from published meta-analyses, whilst a 30% ischaemic stroke reduction for both DOACs was assumed. Cost data for clinical events and pharmaceuticals were collected from the local payer perspective.ResultsCompared with aspirin, dabigatran and rivaroxaban resulted in 17.9 and 29.9 additional bleeding events per 100 patients over a patient's lifetime, respectively. Despite incorporating into our model the proposed 30% reduction in ischaemic stroke risk, both DOACs were cost-additive over patient lifetime, as the costs of bleeding events and pharmaceuticals outweighed cost savings associated with the reduction in ischaemic strokes. DOACs added £5953-£7018 per patient (UK), €6683-€7368 (Netherlands), €4933-€9378 (Spain), AUD$5353-6539 (Australia) and $26,768-$32,259 (US) of payer cost depending on the agent prescribed. Additionally, in the U.S. patient pharmacy co-payments ranged from $2468-$12,844 depending on agent and patient plan. In all settings, cost-savings could not be demonstrated even when the modelling assumed 100% protection from recurrent ischaemic strokes, due to the very low underlying risk of recurrent ischaemic stroke in this population (1.27 per 100 patient-years).ConclusionsAnticoagulation of non-AF patients may cause excess bleeds and add substantial costs for uncertain benefits, suggesting a personalised approach to anticoagulation in ESUS patients.

Dataset Information

Incidence and Predictive Factors of Hidden Atrial Fibrillation Detected by Implantable Loop Recorder After an Embolic Stroke of Undetermined Source.

Publications

Incidence and Predictive Factors of Hidden Atrial Fibrillation Detected by Implantable Loop Recorder After an Embolic Stroke of Undetermined Source.

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