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Cryptogenic Stroke Cardiac Diagnostics and Monitoring

Atrial fibrillation detection and treatment matters

THE CRYPTOGENIC STROKE CHALLENGE

Stroke as a healthcare issue1

THE LINK BETWEEN STROKE AND ATRIAL FIBRILLATION 

Why AF Detection and Treatment Matters for Cryptogenic Stroke Patients

AF Detection Matters Chart

2016 ESC Atrial Fibrillation Guidelines6

Long-term cardiac monitoring recommended for cryptogenic stroke patients

  • Guidelines developed by the Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)
  • Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC
  • Endorsed by the European Stroke Organisation (ESO)

2.5x Increased incidence of AF detection

2.1x Increased incidence of anticoagulant initiation

55% Decreased risk of recurrent stroke

The use of prolonged cardiac monitoring has a potential impact on secondary stroke prevention, as patients with cryptogenic IS/TIA undergoing PCM had higher rates of AF detection and anticoagulant initiation, and lower stroke recurrence.

Download Summary

2019 AHA/ACC/HRS Atrial Fibrillation Guidelines

The 2019 AHA/ACC/HRS atrial fibrillation guidelines provide a Class IIa, Level B-R recommendation for device detection of AF in patients with cryptogenic stroke (i.e., stroke of unknown cause).4

Class of Recommendation (COR)

Level of Evidence (LOE)

Recommendations
I B-NR 1. In patients with cardiac implantable electronic devices (pacemakers or implanted cardioverter-defibrillators), the presence of recorded atrial high-rate episodes (AHREs) should prompt further evaluation to document clinically relevant to AF to guide treatment decisions (S7.12-1-S7.12-5).
IIa* B-R 2. In patients with cryptogenic stroke (i.e., stroke of unknown cause) in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor (loop recorder) is reasonable to optimize detection of silent AF (S7.12-6).

2016 ESC Atrial Fibrillation Guidelines5

Long-term Cardiac Monitoring Recommended for Cryptogenic Stroke Patients

  • Guidelines developed by the Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)
  • Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC
  • Endorsed by the European Stroke Organisation (ESO)

Class

Level

Recommendation

IIa

BB

In stroke patients, additional ECG monitoring by long-term non-invasive ECG monitors or implanted loop recorders should be considered to document silent atrial fibrillation.
Enter Column Header Level Recommendation

IIa

B

In stroke patients, additional ECG monitoring by long-term non- invasive ECG monitors or implanted loop recorders should be considered to document silent atrial fibrillation. 

30 Days of Cardiac Monitoring Is Not Long Enough in Cryptogenic Stroke Patients7

Atrial Fibrillation is frequently asymptomatic and/or paroxysmal

The CRYSTAL-AF Study found that short- and intermediate-term cardiac monitoring may miss many patients with paroxysmal AF.

Crystal AF Boxes Chart

At 12 months, 97% of patients in whom AF was detected received oral anticoagulant6

79% of first AF episodes were asymptomatic at 12 months

88% of patients who had AF would have been missed if only monitored for 30 days†

See CRYSTAL-AF Study Results
*

Class IIa is Benefit >> Risk and LOE B-R is moderate quality of evidence from 1 or more RCTs or meta-analyses of moderate quality RCTs.

†

Based on Kaplan-Meier estimates.

‡

See full brief statement for complete indications for use.

§

ABCD2 Score > 5.

1

Wilkins E, Wilson L, Wickramasinghe K, et al. European Cardiovascular Disease Statistics 2017 edition. Eur Heart Network 2017:192

2

Feng W, Hendry RM, Adams RJ. Risk of recurrent stroke, myocardial infarction, or death in hospitalized stroke patients. Neurology. 2010;74:588–593.

3

Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med. September 1987;147(9):1561-1564.

4

Lin HJ, Kelly-Hayes M, Beiser AS, et al. Stroke Severity in Atrial Fibrillation: The Framingham Study. Stroke. 1996; 27: 1760-1764.

5

Stroke Prevention in Atrial Fibrillation Study. Final results. Circulation. August 1991;84(2):527-539.

6

Kirchhof P, Benussi, S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. Published online August 27, 2016. Accessed online August 31, 2016 at: http://eurheartj.oxfordjournals.org/content/early/2016/08/26/eurheartj.ehw210.

7

Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. June 26, 2014;370(26):2478-2486.

8

Hart RG, Diener HC, Coutts SB, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. April 2014;13(4):429-438.