Atrial fibrillation detection and treatment matters
Cryptogenic stroke accounts for approximately one-third of ischemic strokes in the modern stroke registries and databases.2
Cryptogenic stroke is as prevalent as large vessel 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.
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)
|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).|
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.
The CRYSTAL-AF Study found that short- and intermediate-term cardiac monitoring may miss many patients with paroxysmal AF.
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.
Mozzafarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics – 2015 update: a report from the American Heart Association. Circulation. January 27, 2015;131(4):e29-e322.
Sacco RL, Ellenberg JH, Mohr JP, et al. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol. April 1989;25(4):382-390.
Tsivgoulis G, Katsanos AH, Grory BM, et al. Prolonged Cardiac Rhythm Monitoring and Secondary Stroke Prevention in Patients With Cryptogenic Cerebral Ischemia. Stroke. August 2019;50(8):2175-2180.
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.
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. October 7, 2016;37(38):2893-2962.
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.
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.