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Searching for Atrial Fibrillation Poststroke : A White Paper of the AF-SCREEN International Collaboration

Schnabel, Renate B. ; Haeusler, Karl Georg ; Healey, Jeffrey S. ; Freedman, Ben ; Boriani, Giuseppe ; Brachmann, Johannes ; Brandes, Axel ; Bustamante, Alejandro ; Casadei, Barbara and Crijns, Harry J.G.M. , et al. (2019) In Circulation 140(22). p.1834-1850
Abstract

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with... (More)

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

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publication status
published
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keywords
anticoagulants, atrial fibrillation, cardiomyopathies, electrocardiography, stroke
in
Circulation
volume
140
issue
22
pages
17 pages
publisher
Lippincott Williams and Wilkins
external identifiers
  • scopus:85075532861
  • pmid:31765261
ISSN
1524-4539
DOI
10.1161/CIRCULATIONAHA.119.040267
language
English
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yes
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6d07505f-d423-4858-8033-b3fffd0b305f
date added to LUP
2019-12-04 15:39:21
date last changed
2020-02-19 05:42:42
@article{6d07505f-d423-4858-8033-b3fffd0b305f,
  abstract     = {<p>Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.</p>},
  author       = {Schnabel, Renate B. and Haeusler, Karl Georg and Healey, Jeffrey S. and Freedman, Ben and Boriani, Giuseppe and Brachmann, Johannes and Brandes, Axel and Bustamante, Alejandro and Casadei, Barbara and Crijns, Harry J.G.M. and Doehner, Wolfram and Engström, Gunnar and Fauchier, Laurent and Friberg, Leif and Gladstone, David J. and Glotzer, Taya V. and Goto, Shinya and Hankey, Graeme J. and Harbison, Joseph A. and Hobbs, F. D.Richard and Johnson, Linda S.B. and Kamel, Hooman and Kirchhof, Paulus and Korompoki, Eleni and Krieger, Derk W. and Lip, Gregory Y.H. and Løchen, Maja Lisa and Mairesse, Georges H. and Montaner, Joan and Neubeck, Lis and Ntaios, George and Piccini, Jonathan P. and Potpara, Tatjana S. and Quinn, Terence J. and Reiffel, James A. and Ribeiro, Antonio Luiz Pinho and Rienstra, Michiel and Rosenqvist, Mårten and Sakis, Themistoclakis and Sinner, Moritz F. and Svendsen, Jesper Hastrup and Van Gelder, Isabelle C. and Wachter, Rolf and Wijeratne, Tissa and Yan, Bernard},
  issn         = {1524-4539},
  language     = {eng},
  number       = {22},
  pages        = {1834--1850},
  publisher    = {Lippincott Williams and Wilkins},
  series       = {Circulation},
  title        = {Searching for Atrial Fibrillation Poststroke : A White Paper of the AF-SCREEN International Collaboration},
  url          = {http://dx.doi.org/10.1161/CIRCULATIONAHA.119.040267},
  doi          = {10.1161/CIRCULATIONAHA.119.040267},
  volume       = {140},
  year         = {2019},
}