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Atrial Premature Beats Predict Atrial Fibrillation in Cryptogenic Stroke

2015; Lippincott Williams & Wilkins; Volume: 46; Issue: 4 Linguagem: Inglês

10.1161/strokeaha.115.008714

1524-4628

David J. Gladstone, Paul Dorian, Melanie Spring, Val Panzov, Muhammad Mamdani, Jeff S. Healey, Kevin E. Thorpe, Richard I. Aviv, K. Boyle, J.A. Blakely, Robert Côté, Jillian Hall, Moira K. Kapral, N. Kozlowski, Andreas Laupacis, Martin O’Donnell, K. Sabihuddin, Mukul Sharma, Ashfaq Shuaib, Haris Vaid, Arnold Pintér, Seyedeh Narjes Abootalebi, Richard Chan, S Crann, L. Fleming, C. Frank, Vladimir Hachinski, K Hesser, Balakrishna Kumar, Peter Sörös, Matthew Wright, Vincenzo S. Basile, K. Boyle, J. Hopyan, Y. Rajmohan, Rick Swartz, Haris Vaid, Gregorio Valencia, Jon Erik Ween, Heidi Aram, P. Alan Barber, Shelagh B. Coutts, Andrew M. Demchuk, Katherine Fischer, Michael D. Hill, Gabi Klein, C Kenney, BK Menon, Mark McClelland, Ashley K. Russell, Karla J. Ryckborst, PK Stys, Elaine Smith, Timothy Watson, Sanoj Chacko, Demetrios J. Sahlas, Janice Sancan, Robert Côté, Liam Durcan, Eric Ehrensperger, Jeffrey Minuk, Theodore Wein, Lisa Wadup, Negar Asdaghi, Jeff Beckman, N. Esplana, P. Masigan, Caroline Murphy, Eugene Tang, P. Teal, Karina Villaluna, Andrew R. Woolfenden, Samuel Yip, Miguel Bussière, Dar Dowlatshahi, Mukul Sharma, Grant Stotts, Seafield Robert, Kar- Pinski Ford, Daniel G. Hackam, L. Miners, Tisha Mabb, J. David Spence, Brian Buck, T. Griffin-Stead, R. Jassal, M Siddiqui, Annette Haché, Claudette Lessard, François Lebel, Ariane Mackey, Steve Verreault, C.P Guzmán Astorga, LK Casaubon, Martín del Campo, Cheryl Jaigobin, L Kalman, FL Silver, Lou Atkins, Katherine Coles, Andrew M. Penn, Rachel L. Sargent, Claire Walter, Y. Gable, N. Kadribasic, B Schwindt, Ashfaq Shuaib, Pawel Kostyrko, D. Selchen, Gustavo Saposnik, Patricia D. Christie, Albert Jin, David Hicklin, David Howse, Elinor Edwards, Sharon Jaspers, Faiz Sher, S. Stoger, Darrell Crisp, A. Dhanani, Vincent John, Michael L. Levitan, Manu Mehdiratta, Danny H.K. Wong,

Acute Ischemic Stroke Management

Background and Purpose— Many ischemic strokes or transient ischemic attacks are labeled cryptogenic but may have undetected atrial fibrillation (AF). We sought to identify those most likely to have subclinical AF. Methods— We prospectively studied patients with cryptogenic stroke or transient ischemic attack aged ≥55 years in sinus rhythm, without known AF, enrolled in the intervention arm of the 30 Day Event Monitoring Belt for Recording Atrial Fibrillation After a Cerebral Ischemic Event (EMBRACE) trial. Participants underwent baseline 24-hour Holter ECG poststroke; if AF was not detected, they were randomly assigned to 30-day ECG monitoring with an AF auto-detect external loop recorder. Multivariable logistic regression assessed the association between baseline variables (Holter-detected atrial premature beats [APBs], runs of atrial tachycardia, age, and left atrial enlargement) and subsequent AF detection. Results— Among 237 participants, the median baseline Holter APB count/24 h was 629 (interquartile range, 142–1973) among those who subsequently had AF detected versus 45 (interquartile range, 14–250) in those without AF ( P <0.001). APB count was the only significant predictor of AF detection by 30-day ECG ( P <0.0001), and at 90 days ( P =0.0017) and 2 years ( P =0.0027). Compared with the 16% overall 90-day AF detection rate, the probability of AF increased from <9% among patients with <100 APBs/24 h to 9% to 24% in those with 100 to 499 APBs/24 h, 25% to 37% with 500 to 999 APBs/24 h, 37% to 40% with 1000 to 1499 APBs/24 h, and 40% beyond 1500 APBs/24 h. Conclusions— Among older cryptogenic stroke or transient ischemic attack patients, the number of APBs on a routine 24-hour Holter ECG was a strong dose-dependent independent predictor of prevalent subclinical AF. Those with frequent APBs have a high probability of AF and represent ideal candidates for prolonged ECG monitoring for AF detection. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00846924.