SECONDARY STROKE PREVENTION AF DETECTION AND TREATMENT MATTERS

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Meta-Analysis Summary 

IMPACT OF PROLONGED CARDIAC MONITORING (PCM) ON SECONDARY STROKE PREVENTION

New stroke outcomes data

Prolonged cardiac monitoring (PCM) has higher rates of AF detection and anticoagulant initiation compared to standard of care.

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The meta-analysis included 2 RCTs and 2 observational studies, including a total of 1,102 patients (mean age: 68 years, 41% women). Patients who underwent PCM compared to conventional cardiac monitoring show:

  • 2.5x increased incidence of AF detection (n = 1,102, RR = 2.46, 95% CI: 1.61-3.76, and P < 0.0001)
  • 2.1x increased incidence of anticoagulant initiation (n = 956, RR = 2.07, 95% CI: 1.36-3.17, and  P = 0.0008)
  • 55% decreased risk of recurrent stroke (n = 1,102, RR = 0.45, 95% CI: 0.21-0.97, and P = 0.04)            

Esus Studies

RE-SPECT ESUS + NAVIGATE ESUS RECAP

Detect AF and Inform clinical decisions

The detection of AF in ESUS patients changes the medical management for secondary stroke prevention

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Two large, randomized, controlled trials tested the hypothesis that ESUS patients have reduced recurrent strokes if prescribed a novel oral anticoagulant (NOAC) instead of an antiplatelet regime. There is no proven clinical benefit to anticoagulate all ESUS patients. No evidence of clinical benefit to change current practice for treatment for ESUS (antiplatelet therapy).1 AF detection matters. 67% reduction in stroke risk if you have AF.2

NEUROCARDIOLOGY FOR STROKE

AF DETECTION MATTERS: NEUROCARDIOLOGY PATHWAY NEEDED

Reveal LINQ™ ICM

A diagnostic tool to help inform clinical decisions

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An insertable cardiac monitor (ICM), also known as an implantable loop recorder (ILR), is a small device that is placed just under the skin of the chest that automatically detects and records abnormal heart rhythms for up to 3 years.

Multiple studies have evaluated the ability of ICMs to detect AF in cryptogenic stroke, including CRYSTAL-AF, the largest and most rigorously conducted of these studies. CRYSTAL-AF found that an insertable cardiac monitor is more effective than conventional follow-up for detecting AF in patients with cryptogenic stroke.3 

AHA/ACC/HRS GUIDELINES

GUIDELINES RECOMMEND ICM FOR CRYPTOGENIC STROKE

AF MANAGEMENT GUIDELINES

2019 AHA/ACC/HRS guideline update has a Class IIa recommendation for ICM monitoring in cryptogenic stroke4

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Recommendations for Device Detection of AF Atrial Flutter

Class of Recommendation (COR)

 Level of Evidence (LOE) RECOMMENDATIONS
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).
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*

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.

1

Diener HC. RE-SPECT ESUS: Dabigatran versus Acetylsalicyclic acid for stroke prevention in patients with embolic stroke of undetermined source. Presented at World Stroke Congress 2018; Montreal, Canada.

2

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

3

Sanna T, Diener HC, Passman RS, et al. Cryptogenic Stroke and Underlying Atrial Fibrillation (CRYSTAL AF). N Engl J Med. June 26, 2014;370(26):2478-2486.

4

January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation. July 9, 2019;140(2):e125-e151.