Optimal timing and duration of continuous electrocardiographic monitoring for detecting atrial fibrillation in stroke patients. Atrial fibrillation and paroxysmal atrial fibrillation detection in patients with acute ischemic stroke. Intermittent atrial fibrillation may account for a large proportion of otherwise cryptogenic stroke: a study of 30-day cardiac event monitors. Screening for asymptomatic atrial fibrillation while monitoring the blood pressure at home: trial of regular versus irregular pulse for prevention of stroke (TRIPPS 2.0). A Structured Reading Algorithm Improves Telemetric Detection of Atrial Fibrillation After Acute Ischemic Stroke Noninvasive Cardiac Event Monitoring to Detect Atrial Fibrillation After Ischemic Stroke: A Randomized, Controlled Trial Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL AF): design and rationale. Cryptogenic stroke and underlying atrial fibrillation. Frequent Atrial Premature Beats Predict Paroxysmal Atrial Fibrillation in Stroke Patients: An Opportunity for a New Diagnostic Strategy Holter monitoring in the diagnosis of stroke mechanism. Continuous Stroke Unit Electrocardiographic Monitoring Versus 24-Hour Holter Electrocardiography for Detection of Paroxysmal Atrial Fibrillation After Stroke Atrial Premature Beats Predict Atrial Fibrillation in Cryptogenic Stroke: Results From the EMBRACE Trial Improved Detection of Silent Atrial Fibrillation Using 72-Hour Holter ECG in Patients With Ischemic Stroke: A Prospective Multicenter Cohort Study Rationale and design of the Apixaban for the Reduction of Thrombo‐Embolism in Patients With Device‐Detected Sub‐Clinical Atrial Fibrillation (ARTESiA) trial Detection of atrial fibrillation in patients with acute stroke. Detection of Paroxysmal Atrial Fibrillation in Acute Stroke Patients Uncovering Atrial Fibrillation Beyond Short-Term Monitoring in Cryptogenic Stroke Patients: Three-Year Results From the Cryptogenic Stroke and Underlying Atrial Fibrillation Trial Prevalence of atrial fibrillation with insertable cardiac monitors in cryptogenic stroke: A single-center experience. 96 hours ECG monitoring for patients with ischemic cryptogenic stroke or transient ischaemic attack The Relationship Between Daily Atrial Tachyarrhythmia Burden From Implantable Device Diagnostics and Stroke Risk: The TRENDS Study High-dose atorvastatin and risk of atrial fibrillation in patients with prior stroke or transient ischemic attack: analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Detection of atrial fibrillation in patients with embolic stroke of undetermined source by prolonged monitoring with implantable loop recorders. Performance of a new atrial fibrillation detection algorithm in a miniaturized insertable cardiac monitor: Results from the Reveal LINQ Usability Study. Detection of atrial fibrillation after stroke and the risk of recurrent stroke. Relationship of Sudden Cardiac Death to New-Onset Atrial Fibrillation in Hypertensive Patients With Left Ventricular Hypertrophy Pilot Randomized Trial of Outpatient Cardiac Monitoring After Cryptogenic Stroke Continuous monitoring versus HOLTER ECG for detection of atrial fibrillation in patients with stroke. [Effect of atorvastatin on postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting]. Assessment of Remote Heart Rhythm Sampling Using the AliveCor Heart Monitor to Screen for Atrial Fibrillation: The REHEARSE-AF Study Subclinical atrial fibrillation in patients with recent transient ischemic attack Embolic Strokes of Undetermined Source in the Athens Stroke Registry: A Descriptive Analysis Detection of atrial high-rate events by continuous Home Monitoring: clinical significance in the heart failure–cardiac resynchronization therapy population Relation of recurrence of atrial fibrillation after non-ST-elevation acute myocardial infarction to left atrial abnormality.
BACKGROUND Several studies have suggested that after ischemic stroke , continuous electrocardiographic ( ECG ) monitoring ( CEM ) increases the atrial fibrillation ( AF ) detection rate . However , optimal CEM terms of use are not clear . The aim of our study was to evaluate the usefulness of CEM in detecting AF and define optimal terms of the use of CEM . METHODS We prospect ively enrolled consecutive patients with acute ischemic stroke who were admitted to the stroke unit without AF on baseline ECG . We compared 2 strategies of AF detection : the first using CEM and the second with routine clinical practice ( 24-hour Holter ECG and additional ECGs ) . Adjusted odds ratios for the association between AF diagnosis and the use of CEM stratified by monitoring duration were calculated using multivariate logistic regression analysis . RESULTS Of the 1166 patients included , 220 ( 18.87 % ) had AF on baseline ECG and were excluded . Of the 946 remaining patients , 592 underwent CEM . The prevalence of AF using CEM  was 12.50 % compared 2.26 % using the routine strategy . After adjustment ( demographic data , vascular risk factors , and National Institutes of Health Stroke Scale scores ) , using CEM increased 5.29 fold the odds of finding AF ( 95 % confidence interval [ CI ] 2.43 - 11.55 ) compared to the routine strategy . The adjusted odds ratio ( 9.82 ; 95 % CI 3.01 - 32.07 ) was maximum for the first day of monitoring and decreased later . Beyond 5 days ,  CEM usefulness was not significantly higher than the routine strategy . CONCLUSIONS We suggest that in order to enhance the detection rate of AF , CEM could be generalized in the stroke unit . It must be started early in patients with acute stroke and prolonged over a minimum of 4 days BACKGROUND Studies about continuous electrocardiographic ( ECG ) monitoring in detection of paroxysmal atrial fibrillation ( PAF ) in Asian patients with acute ischemic stroke are very limited . We looked for the prevalence and associated factors of atrial fibrillation ( AF ) and PAF in Thai patients with acute ischemic stroke . METHODS In all , 204 patients with acute ischemic stroke were prospect ively included .  Snapshot 12-lead ECG and continuous ECG monitoring for at least the first 24 hours were performed . Multivariate analyses were performed to find out the associated factors of AF and PAF . RESULTS AF was diagnosed in 31 patients ( 15 % ) and PAF in 15 patients ( 7 % ) . Twelve and 3 patients with PAF were diagnosed by continuous ECG monitoring and snapshot 12-lead ECG , respectively . Mean duration of continuous ECG monitoring and mean time to detect PAF were 55 and 23 hours , respectively . Multivariate analysis revealed that age of 70 years or older ( odds ratio [ OR ] 3.52 , 95 % confidence interval [ CI ] 1.68 - 7.35 , P = .001 ) and heart diseases ( OR 4.26 , 95 % CI 1.14 - 15.95 , P = .031 ) were associated with AF and PAF . CONCLUSIONS AF/PAF was one of the common causes of ischemic stroke in Thai patients . Most PAF was detected by continuous ECG monitoring . Snapshot 12-lead ECG and continuous ECG monitoring should be recommended in all patients with acute ischemic stroke INTRODUCTION Despite extensive inpatient workup including telemetry monitoring , a significant proportion of stroke is classified as cryptogenic at hospital discharge . It is possible that a significant proportion of cryptogenic stroke is a result of intermittent atrial fibrillation ( AF ) . Thirty-day cardiac event monitors ( 30-DEM ) may increase the rate of AF detection compared with st and ard investigations that include a combination of electrocardiography , cardiac telemetry , and short-term Holter monitoring . METHODS Charts were review ed of patients who were admitted to a university stroke center or who were evaluated in the outpatient clinic during a 9-month period to determine whether the cause of stroke was cryptogenic . As a matter of protocol , such patients typically underwent 30-DEM and the results of such monitoring were documented along with the duration of inpatient cardiac monitoring if relevant . RESULTS In all , 218 patients with a diagnosis of ischemic stroke or transient ischemic attack were identified . Of the strokes , 36 ( 16.5 % ) were classified as cryptogenic . Twenty patients with cryptogenic stroke or transient ischemic attack were evaluated with 30-DEM . Four ( 20 % ) were found to have AF , and all 4 patients were treated with warfarin . CONCLUSION The 30-DEM changed the medical treatment of 20 % of patients with otherwise cryptogenic stroke because of the detection of intermittent AF despite no detection of AF on electrocardiography and inpatient telemetry monitoring in the majority of patients . Further prospect i ve studies of extended cardiac event monitors in the setting of cryptogenic stroke are warranted Asymptomatic atrial fibrillation ( AF ) is a common cause of strokes . Physician screening for AF has been recommended . Home screening for AF may increase the likelihood of detecting asymptomatic AF in patients at risk for stroke because of AF . The aim of this study was to assess the feasibility and accuracy of screening for AF when taking home blood pressure ( BP ) measurements using an automatic AF-detecting BP monitor .  Subjects aged > 64 years or those with hypertension , diabetes , congestive heart failure , or previous stroke were enrolled by their primary physicians and given the AF-BP monitor and an electrocardiographic event monitor to use at home for 30 days . The AF-BP monitor reading was compared with the electrocardiographic reading to calculate the sensitivity and specificity of the device for detecting AF . A total of 160 subjects were enrolled , with 10 withdrawing , 1 excluded , and 10 with no AF-BP monitor logs or electrocardiographic recordings . Of the 139 subjects included , 14 had known AF . There was a total of 3,316 days with AF-BP monitor readings and electrocardiographic readings . On the basis of the initial daily AF-BP monitor readings , the AF-BP monitor demonstrated sensitivity of 99.2 % and specificity of 92.9 % for detecting AF . Two subjects with no histories of AF had AF-BP monitor readings of AF that were confirmed by the electrocardiographic monitor . One of these subjects was started on warfarin . In conclusion , home screening for asymptomatic AF while taking BP measurements can be performed accurately . This can be used to detect new AF , allowing treatment with anticoagulation to reduce the future risk for stroke Background and Purpose — Anticoagulation is a highly effective secondary prevention in patients with cardioembolic stroke and atrial fibrillation/flutter ( AF ) . However , the condition remains underdiagnosed , because paroxysmal AF may be missed by diagnostic tests in the acute phase . In this study , the sensitivity of AF detection was assessed for serial electrocardiographic recordings and continuous stroke unit telemetric monitoring with or without a structured algorithm to analyze telemetric data ( SEA-AF ) . Methods — Three hundred forty-six consecutive patients with acute ischemic stroke were prospect ively included and subjected to st and ard telemetric monitoring . In addition , telemetric data were separately analyzed following SEA-AF , consisting of a structured evaluation of episodes with high risk for AF and a chronological beat-to-beat screening of the full registration . Serial electrocardiograms  were conducted in 24-hour intervals . Results — Median effective telemetry monitoring time was 75.5 hours ( interquartile range 64–86 hours ) . Overall , AF was diagnosed in 119 of 346 patients ( 34.4 % ) . The structured reading algorithm was the most sensitive method to detected AF . Conventional telemetry and serial electrocardiographic assessment s were less effective . However , only 35 % of patients with previously documented paroxysmal AF and negative baseline electrocardiogram demonstrated AF episodes during monitoring . Conclusions — Continuous stroke unit telemetry using SEA-AF shows a significantly higher detection rate for AF compared with daily electrocardiographic assessment s and st and ard telemetry without structured reading . The low overall probability to detect paroxysmal AF with either method during the first days after stroke demonstrates the urgent need for complementary diagnostic strategies such as long-term monitoring and frequent follow-up assessment s. Clinical Trial Registration — URL : www . clinical trials.gov . Unique identifier : NCT01177748 Background and Purpose — Atrial fibrillation ( AF ) elevates risk of recurrent stroke but is incompletely identified by st and ard investigation after stroke , though detection rates correlate with monitoring duration . We hypothesized that 7 days of noninvasive cardiac-event monitoring early after stroke would accelerate detection of AF and thus uptake of effective therapy . Methods — We performed a pragmatic r and omized trial with objective outcome assessment among patients presenting in sinus rhythm with no AF history , within 7 days of ischemic stroke symptom onset . Patients were r and omized to st and ard practice investigations ( SP ) to detect AF , or SP plus additional monitoring ( SP-AM ) . AM comprised 7 days of noninvasive cardiac-event monitoring reported by an accredited cardiac electrocardiology laboratory . Primary outcome was detection of AF at 14 days . Results — One-hundred patients were enrolled from 2 centers . Within 14 days of stroke , sustained paroxysms of AF were detected in 18 % of patients undergoing SP-AM versus 2 % undergoing SP ( P<0.05 ) . Paroxysms of any- duration were detected in 44 % of patients undergoing SP-AM versus 4 % undergoing SP ( P<0.001 ) . These differences persisted at 90 days . Anticoagulant therapy was commenced within 14 days in 16 % of SP-AM patients versus none r and omized to SP ( P<0.01 ) . This difference persisted to 90 days ( 22 % versus 6 % ; P<0.05 ) . Conclusions — Routine noninvasive cardiac-event monitoring after acute stroke enhances detection of paroxysmal AF and early anticoagulation . Extended monitoring should be offered to all eligible patients soon after acute stroke . Guidelines on investigation for AF in stroke patients could be strengthened . Clinical Trial Registration — URL : http://www.controlled-trials.com/is rct n/. Unique identifier : IS RCT N97412358 BACKGROUND Patients with atrial fibrillation ( AF ) are at increased risk for ischemic stroke . In patients who have suffered a stroke , screening for AF is routinely performed only for a short period after the stroke as part of the evaluation for possible causes . If AF is detected after an ischemic stroke , oral anticoagulation therapy is recommended for secondary stroke prevention . In 25 % to 30 % of stroke patients , the stroke mechanism can not be determined ( cryptogenic stroke ) . The incidence of paroxysmal AF undetected by short-term monitoring in patients with cryptogenic stroke is unknown , but has important therapeutic implication s on patient care . The optimum monitoring duration and method of AF detection after stroke are unknown . The purpose of this study is to evaluate the incidence of AF and time to AF detection in patients with cryptogenic stroke using an insertable cardiac monitor . STUDY DESIGN The CRYSTAL AF trial is a r and omized prospect i ve study to evaluate a novel approach to long-term monitoring for AF detection in patients with cryptogenic stroke . Four hundred fifty cryptogenic stroke patients ( by definition , without a history of AF ) will be enrolled at approximately 50 sites in Europe , Canada , and the United States . Patients will be r and omized in a 1:1 fashion to st and ard arrhythmia monitoring ( control arm ) or implantation of the subcutaneous cardiac monitor ( Reveal XT ; Medtronic , Inc , Minneapolis , MN ) ( continuous monitoring arm ) . OUTCOMES The primary end point is time to detection of AF within 6 months after stroke . The clinical follow-up period will be at least 12 months . Study completion is expected at the end of 2012 BACKGROUND Current guidelines recommend at least 24 hours of electrocardiographic ( ECG ) monitoring after an ischemic stroke to rule out atrial fibrillation . However , the most effective duration and type of monitoring have not been established , and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40 % of cases ( cryptogenic stroke ) . Detection of atrial fibrillation after cryptogenic stroke has therapeutic implication s. METHODS We conducted a r and omized , controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor ( ICM ) is more effective than conventional follow-up ( control ) for detecting atrial fibrillation in patients with cryptogenic stroke . Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring  underwent r and omization within 90 days after the index event . The primary end point was the time to first detection of atrial fibrillation ( lasting > 30 seconds ) within 6 months . Among the secondary end points was the time to first detection of atrial fibrillation within 12 months . Data were analyzed according to the intention-to-treat principle . RESULTS By 6 months , atrial fibrillation had been detected in 8.9 % of patients in the ICM group ( 19 patients ) versus 1.4 % of patients in the control group ( 3 patients ) ( hazard ratio , 6.4 ; 95 % confidence interval [ CI ] , 1.9 to 21.7 ; P<0.001 ) . By 12 months , atrial fibrillation had been detected in 12.4 % of patients in the ICM group ( 29 patients ) versus 2.0 % of patients in the control group ( 4 patients ) ( hazard ratio , 7.3 ; 95 % CI , 2.6 to 20.8 ; P<0.001 ) . CONCLUSIONS ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke . ( Funded by Medtronic ; CRYSTAL AF Clinical Trials.gov number , NCT00924638 . ) Background and Purpose — For patients having suffered ischemic stroke , the current diagnostic strategies often fail to detect atrial fibrillation as a potential cause of embolic events . The aim of the study was to identify paroxysmal atrial fibrillation in stroke patients . We hypothesized that patients with frequent atrial premature beats ( APBs ) recorded in 24-hour ECG will show more often atrial fibrillation when followed by repeated long-term ECG recordings than patients without or infrequent APBs . Methods — 127 patients with acute ischemic stroke and without known AF were enrolled in a prospect i ve study to detect paroxysmal AF . Patients were stratified according to the number of APBs recorded in a 24-hour ECG ( ≥70 APBs versus < 70 APBs ) . Subsequently , they all underwent serial 7-day event-recorder monitoring at 0 , 3 , and 6 months . Results — Serial extended ECG monitoring  identified AF in 26 % of patients with frequent APBs but only in 6.5 % when APBs were infrequent ( P=0.0021 ) . A multivariate analysis showed that the presence of frequent APBs in the initial 24-hour ECG was the only independent predictor of paroxysmal AF during follow-up ( odds ratio 6.6 , 95 % confidence intervals 1.6 to 28.2 , P=0.01 ) . Conclusions — In patients with acute ischemic stroke , frequent APBs ( ≥70/24 hours ) are a marker for individuals who are at greater risk to develop or have paroxysmal AF . For such patients , we propose a diagnostic workup with repeated prolonged ECG monitoring to diagnose paroxysmal AF BACKGROUND Atrial fibrillation ( AF ) , an important and treatable cause of ischaemic stroke , can occur as a sustained or a paroxysmal arrhythmia . Continuous cardiac rhythm monitoring ( Holter monitoring ) is often performed in stroke patients to identify paroxysmal AF , which is an indication for warfarin anti-coagulation in this patient population . AIM The aim of this study was to assess the clinical utility of Holter monitoring in detecting occult AF in patients with possible cardioembolic stroke . METHODS The medical records of ischaemic stroke patients consecutively hospitalized at a single academic centre during a one-year period were review ed . Data regarding patient demographics , stroke characteristics , electrocardiography and echocardiography results and duration and findings of Holter monitoring were abstract ed . The primary outcome was yield of newly diagnosed AF on Holter monitoring .  RESULTS Of 465 consecutive patients admitted with a diagnosis of new ischaemic stroke , 210 underwent Holter monitoring . The mean duration of monitoring was 22.8 + /- 4.0 h. Previously undiscovered AF was -identified in five cases ( 2.4 % ) , all of which represented non-rheumatic AF . In three cases , the Holter test was negative despite AF documented on an admission electro-cardiogram . CONCLUSIONS Holter monitoring can identify occult paroxysmal AF , assisting targeted secondary prevention in patients with new ischaemic stroke . However , the st and ard 24-h duration of monitoring probably under-estimates the prevalence of paroxysmal AF in this population . Prospect i ve studies are indicated to evaluate the value of longer monitoring periods in stroke population Background and Purpose — Cardioembolism in paroxysmal atrial fibrillation ( pxAF ) is a frequent cause of ischemic stroke . Sensitive detection of pxAF after stroke is crucial for adequate secondary stroke prevention ; the optimal diagnostic modality to detect pxAF on stroke units is unknown . We compared 24-hour Holter electrocardiography ( ECG ) with continuous stroke unit ECG monitoring ( CEM ) for pxAF detection . Methods — Patients with acute ischemic stroke or transient ischemic attack were prospect ively enrolled . After a 12-channel ECG on admission , all patients received 24-hour Holter ECG and CEM . Additionally , ECG monitoring data underwent automated analysis using dedicated software to identify pxAF . Patients with a history of atrial fibrillation or with atrial fibrillation on the admission ECG were excluded . Results — Four hundred ninety-six patients ( median age , 69 years ; 61.5 % male ) fulfilled all inclusion criteria ( ischemic stroke : 80.4 % ; transient ischemic attack : 19.6 % ) . Median stroke unit stay lasted 88.8 hours ( interquartile range , 65.0–122.0 ) .  ECG data  for automated CEM analysis were available for a median time of 64.0 hours ( 43.0–89.8 ) . Paroxysmal AF was documented in 41 of 496 patients ( 8.3 % ) . Of these , Holter detected pxAF in 34.1 % ; CEM in 65.9 % ; and automated CEM in 92.7 % . CEM and automated CEM detected significantly more patients with pxAF than Holter ( P<0.001 ) , and automated CEM detected more patients than CEM ( P<0.001 ) . Conclusions — Automated analysis of CEM improves pxAF detection in patients with stroke on stroke units compared with 24-hour Holter ECG . The comparative usefulness of prolonged or repetitive Holter ECG recordings requires further evaluation 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 sub clinical AF . Methods — We prospect ively 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 r and omly 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 sub clinical AF . Those with frequent APBs have a high probability of AF and represent ideal c and i date s for prolonged ECG monitoring for AF detection . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00846924 Background and Purpose — Adequate diagnosis of atrial fibrillation ( AF ) , including paroxysmal AF , is an important part of stroke workup . Prolonged ECG monitoring may improve the detection of paroxysmal , previously undiagnosed AF ( unknown AF ) . Therefore , we evaluated systematic 72-hour Holter ECG monitoring to detect unknown AF for the workup of patients with stroke . Methods — Unselected survivors of a stroke or transient ischemic attack ( TIA ) without known AF were enrolled in a prospect i ve , multicenter cohort study of 72-hour Holter ECG monitoring in 9 German secondary and tertiary stroke centers between May 2010 and January 2011 . In addition to st and ardized workup of stroke pathogenesis according to the German Stroke Unit protocol , all patients underwent 72-hour Holter ECG monitoring directly after admission . All ECGs were central ly analyzed by 2 independent observers . We determined the proportion of unknown AF and compared the detection rates of 72- and 24-hour monitoring . Results — A total of 1135 patients were enrolled ( mean age , 67 years [ SD , 13.1 years ] , 45 % women , 29 % TIA ) .  Unknown AF was detected in 49 out of 1135 patients ( 4.3 % , [ 95 % confidence interval , 3.4–5.2 % ] ) by 72-hour ECG monitoring .  Unknown AF was diagnosed in 29 patients ( 2.6 % ) within the first 24 hours of ECG monitoring , and in 20 more patients only by 72 hours of ECG monitoring . The number needed to screen by 72-hour ECG was 55 patients ( 95 % confidence interval [ 35–123 ] ) for each additional AF diagnosis . Patients with unknown AF were significantly older and had more often a history of previous stroke . Patients with unknown AF were equally distributed within categories of pathogenesis according to Trial of Org 10172 in Acute Stroke Treatment ( TOAST ) classification . Conclusions — In unselected survivors of stroke or TIA , 72-hour ECG monitoring is feasible and improves the detection rate of silent paroxysmal AF Background Device‐detected sub clinical atrial fibrillation ( AF ) refers to infrequent , short‐lasting , asymptomatic AF that is detected only with long‐term continuous monitoring . Sub clinical AF is common and associated with an increased risk of stroke ; however , the risk of stroke with sub clinical AF is lower than for clinical AF , and very few patients with sub clinical AF alone have been included in large AF anticoagulation trials . The net benefit of anticoagulation in patients with sub clinical AF is unknown . Design ARTESiA is a prospect i ve , multicenter , double‐blind , r and omized controlled trial , recruiting patients with sub clinical AF detected by an implanted pacemaker , defibrillator , or cardiac monitor , and who have additional risk factors for stroke . Patients with clinical AF documented by surface electrocardiogram will be excluded from the study . Participants will be r and omized to receive either apixaban ( according to st and ard AF dosing ) or aspirin 81 mg daily . The primary outcome is the composite of stroke , transient ischemic attack with diffusion‐weighted magnetic resonance imaging evidence of cerebral infa rct ion , and systemic embolism . Approximately 4,000 patients will be enrolled from around 230 clinical sites , with an anticipated mean follow‐up of 36 months until 248 adjudicated primary outcome events have occurred . Summary ARTESiA will determine whether oral anticoagulation therapy with apixaban compared with aspirin reduces the risk of stroke or systemic embolism in patients with sub clinical AF and additional risk factors Atrial fibrillation ( AF ) and paroxysmal AF ( PAF ) are common causes of stroke which may not be detected by a single electrocardiogram ( EKG ) . We conducted a prospect i ve study to determine if 48 hours of telemetry monitoring increased the rate of detection of AF in patients with acute stroke and thus identified patients requiring anticoagulation . One hundred and fifty consecutive patients with acute ischemic stroke were placed on telemetry monitoring for 48 hours . Thirty-five patients had AF related strokes . There were 12 patients with AF related stroke who did not have a previous history of AF and were found to have AF following the stroke . Six of these 12 patients were found to have AF on their admission EKG . The remaining six patients had normal admission EKGs and were diagnosed with AF only during telemetry monitoring for 48 hrs . Patients with AF were older , had larger strokes , which were more likely to be non-lacunar , than patients without AF . Our study suggests that AF is sometimes undiagnosed until a stroke occurs . Improved methods of detection of AF are needed in high-risk patients for primary stroke prevention . Patients older than 65 years of age with non-lacunar strokes should have 48 hours of telemetry monitoring to detect previously undiagnosed AF Background : Atrial fibrillation ( AF ) is a frequent cause of stroke , but detecting paroxysmal AF ( pAF ) poses a challenge . We investigated whether continuous bedside ECG monitoring in a stroke unit detects pAF more sensitively than 24-hour Holter ECG , and tested whether examining RR interval dynamics on short-term ECG recordings using an automated screening algorithm ( ASA ) for pAF detection is a useful tool to predict the risk of pAF outside periods of manifest AF . Methods : Patients > 60 years with acute ischemic stroke or transient ischemic attacks ( TIA ) were prospect ively enrolled unless initial ECG revealed AF or they had a history of paroxysmal or persistent AF . ASA was performed on 1- to 2-hour ECG recordings in the emergency room and patients were classified into 5 risk categories for pAF . All patients underwent continuous bedside ECG monitoring for > 48 h. Additionally , 24-hour Holter ECG was performed . Results : 136 patients were enrolled ( median age : 72 years , male : 58.8 % ) . In 29 ( 21.3 % ) , pAF was newly diagnosed by continuous bedside ECG monitoring . pAF increased with age ( p = 0.031 ) . Median time to first pAF detection on continuous bedside ECG monitoring was 36 h. In 16 patients , pAF was detected by continuous bedside ECG monitoring prior to the performance of 24-hour Holter ECG . Thirteen of the remaining patients were pAF positive on continuous bedside ECG monitoring , but 24-hour Holter detected only 3 patients . Accordingly , the sensitivity of 24-hour Holter was 0.23 . Sensitivity of higher-risk categories of ASA compared to continuous bedside ECG monitoring was 0.72 , and specificity 0.63 . Conclusion : Continuous bedside ECG monitoring is more sensitive than 24-hour Holter ECG for pAF detection in acute stroke/TIA patients . Screening patients for pAF outside AF episodes using ASA requires further development Background —Atrial fibrillation ( AF ) can be a cause of previously diagnosed cryptogenic stroke . However , AF can be paroxysmal and asymptomatic , thereby making detection with routine ECG methods difficult . Oral anticoagulation is highly effective in reducing recurrent stroke in patients with AF , but its initiation is dependent on the detection of AF . Cryptogenic Stroke and Underlying Atrial Fibrillation ( CRYSTAL AF ) is the first r and omized study to report the detection of AF in cryptogenic stroke patients using continuous long-term monitoring via insertable cardiac monitors ( ICM ) . Methods and Results — Patients with prior cryptogenic stroke were r and omized to control ( n=220 ) or ICM ( n=221 ) and followed for ⩽36 months . Cumulative AF detection rates in the ICM arm increased progressively during this period ( 3.7 % , 8.9 % , 12.4 % , and 30.0 % at 1 , 6 , 12 , and 36 months , respectively ) , but remained low in the control arm ( 3.0 % at 36 months ) . This result ed in oral anticoagulation prescription in 94.7 % of ICM patients with AF detected at 6 months , 96.6 % at 12 months , and 90.5 % at 36 months . Among ICM patients with AF detected , the median time to AF detection was 8.4 months , 81.0 % of first AF episodes were asymptomatic , and 94.9 % had at least 1 day with > 6 minutes of AF . Conclusions —Three-year monitoring by ICM in cryptogenic stroke patients demonstrated a significantly higher AF detection rate compared with routine care . Given the frequency of asymptomatic first episodes and the long median time to detection , these findings highlight the limitations of using traditional AF detection methods . The majority of patients with AF were prescribed oral anticoagulation therapy . Clinical Trial Registration — Clinical trials.gov ; Unique identifier : NCT00924638 BACKGROUND The use of insertable cardiac monitors ( ICM ) has increased the rate of detection of atrial fibrillation ( AF ) among cryptogenic stroke ( CS ) patients . We describe a single-center experience for AF detection among CS patients receiving ICMs upon discharge after the index stroke event and attempt to identify predictors for AF detection . METHODS From April 2014 to October 2017 , patients receiving ICMs for CS who underwent > 60 days of monitoring were review ed . Chronic underlying medical illnesses , presence of left atrial enlargement ( LAE ) on echocardiography , and PR interval on admission electrocardiogram were assessed as predictors of AF detection . RESULTS A total of 234 patients ( median age 72 [ 61 , 78 ] years , 45 % women ) met inclusion criteria and were followed for a median of 536 [ 282 , 848 ] days . Among studied patients , 68 patients ( 29 % ) were found to have AF at a median of 94.5 [ 16 , 239 ] days from ICM placement . CS patients with AF were significantly older ( p < 0.001 ) , and there was a significantly higher proportion of women ( p = 0.003 ) when compared to CS patients without AF . Neither presence of LAE nor prolonged PR interval was predictive of AF detection . CONCLUSION Almost one-third of CS patients monitored with an ICM were found to have previously undiagnosed AF . CS patients found to have AF were older and more commonly women . Prospect i ve studies are needed to better identify predictors for early AF among the broader population of all CS patients Atrial fibrillation ( AF ) is intermittent in 30 % of patients with cardioembolic stroke and , therefore , might not be seen in a single st and ard ECG recording . The aim of this study was to evaluate if prolonged ECG monitoring ( 96 h ) finds episodes of intermittent AF beyond the 24 h ECG monitoring in patients with cryptogenic stroke or transient ischemic attack ( TIA ) . We prospect ively evaluated consecutive patients affected by cryptogenic stroke or TIA who had sinus rhythm on a 12-lead ECG on admission , and during ECG monitoring performed in the acute phase ( for at least 24 h ) . Patients had continuous 96 h Holter ECG monitoring within 30 days from stroke onset . 114 patients were included in the study ( mean age 63.1 ± 15.1 , 59 males ) .  AF was found in 29 patients ( 24.3 % ) . In 20 patients , AF was found in the first 24 h of recording , and in nine patients after 24 h. In addition , several other dysrhythmias such as supraventricular ectopic activity ( 33 ) , ventricular tachycardia ( 10 ) , sinus pause ( 4 ) and sinus-atrial block ( 1 ) were found . In patients with cryptogenic stroke or TIA , 96 h ECG monitoring detected a high rate of AF . One-third of AF was seen beyond 24 h of ECG monitoring Background —It is unknown if brief episodes of device-detected atrial fibrillation ( AF ) increase thromboembolic event ( TE ) risk . Methods and Results —TRENDS was a prospect i ve , observational study enrolling patients with ≥1 stroke risk factor ( heart failure , hypertension , age ≥65 years , diabetes , or prior TE ) receiving pacemakers or defibrillators that monitor atrial tachycardia (AT)/AF burden ( defined as the longest total AT/AF duration on any given day during the prior 30-day period ) . This time-varying exposure was up date d daily during follow-up and related to TE risk . Annualized TE rates were determined according to AT/AF burden subsets : zero , low ( < 5.5 hours [ median duration of subsets with nonzero burden ] ) , and high ( ≥5.5 hours ) . A multivariate Cox model provided hazard ratios including terms for stroke risk factors and time-varying AT/AF burden and antithrombotic therapy . Patients ( n=2486 ) had at least 30 days of device data for analysis . During a mean follow-up of 1.4 years , annualized TE risk ( including transient ischemic attacks ) was 1.1 % for zero , 1.1 % for low , and 2.4 % for high burden subsets of 30-day windows . Compared with zero burden , adjusted hazard ratios ( 95 % CIs ) in the low and high burden subsets were 0.98 ( 0.34 to 2.82 , P=0.97 ) and 2.20 ( 0.96 to 5.05 , P=0.06 ) , respectively . Conclusions —The TE rate was low compared with patients with traditional AF with similar risk profiles . The data suggest that TE risk is a quantitative function of AT/AF burden . AT/AF burden ≥5.5 hours on any of 30 prior days appeared to double TE risk . Additional studies are needed to more precisely investigate the relationship between stroke risk and AT/AF burden BACKGROUND Observational analyses and short-term r and omized trials have suggested that statins reduce occurrence or recurrence of atrial fibrillation ( AF ) . We tested the hypothesis that long-term treatment with high-dose atorvastatin reduces occurrence of AF in patients with prior stroke or transient ischemic attack . METHODS We examined development of new AF in the SPARCL trial that compared atorvastatin 80 mg daily with placebo in 4,731 patients with prior stroke or transient ischemic attack . Patients who had chronic or paroxysmal AF or were taking medications for treatment or prophylaxis of AF at the time of enrollment were excluded .  Atrial fibrillation was identified from electrocardiograms su bmi tted to a blinded central electrocardiographic laboratory and from investigators ' adverse event reports . RESULTS Patients were followed up for a median of 4.8 years , corresponding to > 20,000 patient-years of observation with a median of 5 electrocardiograms per patient . The primary efficacy measure , the time from r and omization to first occurrence of new AF , did not differ between treatment groups . By intention to treat , there were 139 cases of new AF in the atorvastatin group and 122 cases in the placebo group , corresponding to incidence rates of 1.32 and 1.14 cases per 100 patient-years observation ( hazard ratio 1.15 , 95 % CI 0.90 - 1.46 , P = .26 ) . On-treatment analysis yielded similar findings , with incidence rates of 1.26 and 1.01 cases per 100 patient-years observation in the atorvastatin and placebo groups , respectively ( hazard ratio 1.25 , 95 % CI 0.94 - 1.67 , P = .12 ) . CONCLUSION High-dose atorvastatin does not prevent development of AF in patients with prior stroke or transient ischemic attack Screening for  atrial fibrillation ( AF ) by assessing the pulse is recommended in high-risk patients . Some clinical trials demonstrated that the Microlife blood pressure monitor ( BPM ) with AF detection is more accurate than pulse palpation . This led to a change in practice guidelines in the United Kingdom where AF screening with the Microlife device is recommended instead of pulse palpation . Many BPMs have irregular heart beat detection , but they have not been shown to detect AF reliably . Recently , one study , in a highly select population , suggested that the Omron BPM with irregular heart beat detection has a higher sensitivity for AF than the Microlife BPM . We compared the Microlife and Omron BPMs to electrocardiographic readings for AF detection in general cardiology patients . Inclusion criteria were age≥50 years without a pacemaker or defibrillator . A total of 199 subjects were enrolled , 30 with AF . Each subject had a 12-lead electrocardiography , 1 Omron BPM reading , and 3 Microlife BPM readings as per device instructions . The Omron device had a sensitivity of 30 % ( 95 % confidence interval [ CI ] 15.4 % to 49.1 % ) with the sensitivity for the first Microlife reading of 97 % ( 95 % CI 81.4 % to 100 % ) and the Microlife readings using the majority rule ( AF positive if at least 2 of 3 individual readings were positive for AF ) of 100 % ( 95 % CI 85.9 % to 100 % ) . Specificity for the Omron device was 97 % ( 95 % CI 92.5 % to 99.2 % ) and for the first Microlife reading of 90 % ( 95 % CI 83.8 % to 94.2 % ) and for the majority rule Microlife device of 92 % ( 95 % CI 86.2 % to 95.7 % ; p<0.0001 ) . The specificity of both devices is acceptable , but only the Microlife BPM has a sensitivity value that is high enough to be used for AF screening in clinical practice Recently , the clinical entity embolic stroke of undetermined source ( ESUS ) has been defined for patients with ischemic strokes , where neither a cardioembolic nor a non-cardiac source can be detected . These patients may suffer from asymptomatic atrial fibrillation ( AF ) , terminating spontaneously and thus eluding detection . Implantable loop recorders ( ILR ) with automatic AF detection algorithms can detect short-lasting , sub clinical AF . The aim of this study was to prospect ively assess and predict AF detection in patients with ESUS using ILR with daily remote interrogation . Patients with acute ESUS received an ILR , were seen every 6 months and additionally interrogated their ILR daily using remote monitoring . The incidence of AF detection was assessed and parameters which might predict AF detection ( clinical and from magnetic resonance tomography ) were analysed . ILR implantation was performed in 123 patients on average 20 days after stroke . During a mean follow-up of 12.7±5.5 months , AF was documented and manually confirmed in 29 of 123 patients ( 23.6 % ) . First AF detection occurred on average after 3.6±3.4 months of monitoring . Patients with AF were on average older , had a higher CHA2DS2-VASc score and more often cerebral microangiopathy . In conclusion , AF can be documented in approximately 25 % of patients with the diagnosis of ESUS after careful work-up within a year of monitoring by an ILR and daily remote interrogation . This had important therapeutic consequences ( initiation of anticoagulation for secondary stroke prevention ) in these patients BACKGROUND For clinicians , confidence in atrial fibrillation ( AF ) episode classification is an important consideration when electing to use insertable cardiac monitors ( ICMs ) . OBJECTIVE The purpose of this study was to report on the improved AF detection algorithm in the Reveal LINQ ICM . METHODS The Reveal LINQ Usability Study is a nonr and omized , prospect i ve , multicenter trial . The ICM has been miniaturized , uses wireless telemetry for remote patient monitoring , and its AF algorithm includes a new p-wave filter . At 1 month post-device insertion , Holter monitor data were collected and annotated for true AF episodes ≥2 minutes , and performance metrics were evaluated by comparing Holter annotations with ICM detections . RESULTS The study enrolled 151 patients ( age 56.6 ± 12.1 , male 67 % ) . Reasons for monitoring included  AF ablation or AF management in 81.5 % ( n = 123 ) , syncope in 12.6 % ( n = 19 ) , and other indications in 5.9 % ( n = 9 ) of patients . Of the 138 patients with an analyzable Holter recording , a total of 112 true AF episodes were identified in 38 patients ( 27.5 % ) . The overall accuracy of the ICM to detect duration s of AF or non-AF episodes was 99.4 % , and the AF burden measured by the ICM was highly correlated with the Holter ( Pearson coefficient 0.995 ) . CONCLUSION The new AF detection algorithm in the Reveal LINQ ICM accurately detects the presence or absence of AF . Additionally , it showed high sensitivity in detecting AF duration in patients with a history of intermittent and symptomatic AF Failure to expeditiously diagnose atrial fibrillation ( AF ) as the cause of ischemic stroke has unclear consequences . We studied the association between detection of AF after discharge and the risk of recurrent stroke . We followed a prospect ively assembled cohort of patients hospitalized for stroke for 1 year for new diagnoses of AF and recurrent stroke . We compared rates of recurrent stroke in patients with a new diagnosis of AF and those without a new diagnosis of AF after discharge using Kaplan-Meier survival statistics . We conducted Cox proportional hazards analysis of the diagnosis and timing of AF and recurrent stroke after adjustment for age , sex , race , preexisting AF , hypertension , dyslipidemia , diabetes , previous stroke , and use of antithrombotic and statin medications . Among 5575 patients with stroke , 113 ( 2.0 % ) received a new diagnosis of AF after discharge , and 221 ( 4.0 % ) had recurrent stroke . At 1 year , the Kaplan‒Meier rate of recurrent stroke was 18.9 % in those with a new diagnosis of AF and 4.5 % in others , including those with AF diagnosed before or during the index hospitalization ( P = .001 ) . The association between a new diagnosis of AF and stroke recurrence persisted after adjustment for potential confounders ( hazard ratio , 5.6 ; 95 % confidence interval , 3.4 - 9.1 ) . A new diagnosis of AF after discharge for stroke is associated with an increased risk of recurrent stroke , even compared with patients with known AF . These findings identify a subset of patients at high risk for recurrent stroke and highlight the importance of timely detection of AF in patients with stroke Background —Prevalent atrial fibrillation ( AF ) is associated with a higher sudden cardiac death ( SCD ) rate in some population s , and incident AF predicts increased mortality risk in the general population and after myocardial infa rct ion . However , the relationship of SCD to new-onset AF is unclear . Methods and Results —The relationship of SCD to new-onset AF was evaluated in 8831 hypertensive patients with electrocardiographic left ventricular hypertrophy with no history of AF , in sinus rhythm on their baseline electrocardiogram , r and omly assigned to losartan- or atenolol-based treatment . During 4.7±1.1 years mean follow-up , new-onset AF occurred in 701 patients ( 7.9 % ) and SCD in 151 patients ( 1.7 % ) . In univariate Cox analyses , new-onset AF was associated with a > 4-fold higher risk of SCD ( hazard ratio , 4.69 ; 95 % CI interval , 2.96–7.45 ; P<0.001 ) . In multivariate Cox analyses adjusting for age , sex , race , diabetes mellitus , history of heart failure , myocardial infa rct ion , ischemic heart disease , stroke , smoking , serum high-density lipoprotein cholesterol , creatinine , glucose , and urine albumin/creatinine ratio as st and ard risk factors , and for incident myocardial infa rct ion , in-treatment use of digoxin , systolic and diastolic pressure , heart rate , QRS duration , Cornell voltage- duration product , and Sokolow-Lyon voltage left ventricular hypertrophy treated as time-varying covariates , new-onset AF remained associated with a > 3-fold increased risk of SCD ( hazard ratio , 3.13 ; 95 % confidence interval , 1.87–5.24 ; P<0.001 ) . Conclusions —Development of new-onset AF identifies hypertensive patients at  increased risk of SCD . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00338260 Background and Purpose — Observational studies indicate that outpatient cardiac monitoring detects previously undiagnosed atrial fibrillation ( AF ) in 5 % to 20 % of patients with recent stroke . However , it remains unknown whether the yield of monitoring exceeds that of routine clinical follow-up . Methods — In a pilot trial , we r and omly assigned 40 patients with cryptogenic ischemic stroke or high-risk transient ischemic attack to wear a Cardionet mobile cardiac outpatient telemetry monitor for 21 days or to receive routine follow-up alone . After thorough investigation , we excluded patients with documented AF or other apparent stroke pathogenesis . We contacted patients and their physicians at 3 months and at 1 year to ascertain any diagnoses of AF or recurrent stroke or transient ischemic attack . Results — The baseline characteristics of our cohort broadly matched those of previous observational studies of monitoring after stroke . In the monitoring group , patients wore monitors for 64 % of the assigned days , and 25 % of patients were not compliant at all with monitoring . No patient in either study arm received a diagnosis of AF . Cardiac monitoring revealed AF in zero patients ( 0 % ; 95 % confidence interval , 0%–17 % ) , brief episodes of atrial tachycardia in 2 patients ( 10 % ; 95 % confidence interval , 1%–32 % ) , and nonsustained ventricular tachycardia in 2 patients ( 10 % ; 95 % confidence interval , 1%–32 % ) . Conclusions — In the first reported r and omized trial of cardiac monitoring after cryptogenic stroke , the rate of AF detection was lower than expected , incidental arrhythmias were frequent , and compliance with monitoring was suboptimal . Our findings highlight the challenges of prospect ively identifying stroke patients at risk for harboring paroxysmal AF and ensuring adequate compliance with cardiac monitoring . Clinical Trial Registration — URL : http:// clinical trials.gov . Unique Identifier : BACKGROUND AND PURPOSE Detection of atrial fibrillation is of vital importance because oral anticoagulation decreases the risk of a stroke by 64 % . Current st and ards for stroke unit treatment require continuous electrocardiogram ( ECG ) monitoring for at least 24 h. Additionally , a 24-h HOLTER ECG ( HOLTER ) should be performed in selected patients . It remains unclear whether continuous monitoring at the bedside is equivalent to HOLTER for the detection of atrial fibrillation . Furthermore , we investigate how many additional patients with paroxysmal atrial fibrillation can be identified as a result of a longer duration of continuous monitoring . METHODS In this study , we prospect ively compared the detection rates of HOLTER and 24-h monitoring at the Stroke Unit at the University of Heidelberg over a period of 9 months . Continuous monitoring was analyzed by trained nurses , HOLTER by cardiologists . RESULTS We included 370 patients with ischemic stroke or transient ischemic attack ( TIA ) in our study . Of these , 192 patients underwent HOLTER . Previously unknown atrial fibrillation was detected in 44 patients , 13 patients had no atrial fibrillation in baseline ECG , but  atrial fibrillation  was detected by continuous monitoring . In two patients , the HOLTER showed atrial fibrillation ; both patients had also been detected by continuous monitoring . Median time to detection of the atrial fibrillation during continuous monitoring was 43 h after hospitalization . CONCLUSION In this study , use of HOLTER does not give any additional benefit in comparison with continuous monitoring with intermittent analysis by trained staff alone . The median detection time of 43 h emphasizes the importance of longer continuous monitoring OBJECTIVE To evaluate the effect of atorvastatin on  postoperative atrial fibrillation ( AF ) in patients undergoing coronary artery bypass grafting ( CABG ) . METHODS A cohort of 140 consecutive patients without a history of documented AF or previous statin use , who were scheduled to undergo selective CABG , were enrolled . Included patients were r and omly assigned to atorvastatin group ( n = 71 ) who were administered atorvastatin 20 mg/d or to control group ( n = 69 ) . After CABG , subjects were monitored continuously by electrocardiographic monitors at least 7 days . During the initial postoperative 7 d , the incidence and duration of AF were recorded . And the levels of high-sensitivity C-reactive protein ( hs-CRP ) were measured before and 24 hours , 72 hours , 7 days after operation , respectively . The statistical software package SPSS ( version 13.0 ) were used to analyze the data . The differences between groups were evaluated by chi(2)-test for discrete variables and student t-test for continuous variables . Multivariate logistic regression analysis was performed to determine the independent predictors of early postoperative AF . RESULTS During initial postoperative 7 d , AF occurred at least once in 10 cases in atorvastatin group , with a prevalence of roughly 14 % , and in 23 cases in control group , with a prevalence of approximately 34 % ( P = 0.009 ) . The mean duration of single AF was 3.6 + /- 0.4 hours in atorvastatin group and 5.7 + /- 0.5 hours in control group ( P < 0.01 ) , respectively . The multivariate logistic analysis showed that perioperative atorvastatin administration was an independently risk factor for early postoperative AF ( OR = 0.219 , 0.076 - 0.633 , P = 0.005 ) . There was also statistical difference in hs-CRP after CABG between the two groups . CONCLUSIONS Perioperative atorvastatin administration may inhibit inflammatory reaction , reduce the incidence and duration of postoperative AF , hence may prevent and treat postoperative AF Background : Asymptomatic atrial fibrillation ( AF ) is increasingly common in the aging population and implicated in many ischemic strokes . Earlier identification of AF with appropriate anticoagulation may decrease stroke morbidity and mortality . Methods : We conducted a r and omized controlled trial of AF screening using an AliveCor Kardia monitor attached to a WiFi-enabled iPod to obtain ECGs ( iECGs ) in ambulatory patients . Patients ≥65 years of age with a CHADS-VASc score ≥2 free from AF were r and omized to the iECG arm or routine care ( RC ) . iECG participants acquired iECGs twice weekly over 12 months ( plus additional iECGs if symptomatic ) onto a secure study server with overread by an automated AF detection algorithm and by a cardiac physiologist and /or consultant cardiologist . Time to diagnosis of AF was the primary outcome measure . The overall cost of the devices , ECG interpretation , and patient management were captured and used to generate the cost per AF diagnosis in iECG patients . Clinical events and patient attitudes/experience were also evaluated . Results : We studied 1001 patients ( 500 iECG , 501 RC ) who were 72.6±5.4 years of age ; 534 were female . Mean CHADS-VASc score was 3.0 ( heart failure , 1.4 % ; hypertension , 54 % ; diabetes mellitus , 30 % ; prior stroke/transient ischemic attack , 6.5 % ; arterial disease , 15.9 % ; all CHADS-VASc risk factors were evenly distributed between groups ) . Nineteen patients in the iECG group were diagnosed with AF over the 12-month study period versus 5 in the RC arm ( hazard ratio , 3.9 ; 95 % confidence interval=1.4–10.4 ; P=0.007 ) at a cost per AF diagnosis of $ 10 780 ( £ 8255 ) . There was a similar number of stroke/transient ischemic attack/systemic embolic events ( 6 versus 10 , iECG versus RC ; hazard ratio=0.61 ; 95 % confidence interval=0.22–1.69 ; P=0.34 ) . The majority of iECG patients were satisfied with the device , finding it easy to use without restricting activities or causing anxiety . Conclusions : Screening with twice-weekly single-lead iECG with remote interpretation in ambulatory patients ≥65 years of age at increased risk of stroke is significantly more likely to identify incident AF than RC over a 12-month period . This approach is also highly acceptable to this group of patients , supporting further evaluation in an appropriately powered , event-driven clinical trial . Clinical Trial Registration : URL : https://www.is rct n.com . Unique identifier : IS RCT N10709813 BACKGROUND Atrial fibrillation ( AF ) is a major risk factor of stroke , but the association between AF and transient ischemic attack ( TIA ) is less clear . Despite this , patients with TIA are included in stroke trials . AIMS To determine the 1-year incidence of AF in TIA patients using an insertable cardiac monitor ( ICM ) ; second , to determine factors associated with incident AF in these patients . METHODS Prospect i ve cohort study of patients with TIA with normal st and ard electrocardiogram ( ECG ) and 72-hour Holter monitoring ( HM ) . Exclusion criteria were as follows : age < 18 or > 81 years ; prior AF/stroke ; ongoing oral anticoagulation therapy or contraindication for it ; significant carotid artery stenosis ; uncertain TIA diagnosis . Eligible patients received an ICM and were followed for 12 months . RESULTS From November 2013 to October 2015 , 809 patients were diagnosed with TIA . In total , 235 patients were eligible . Nine ( 3.8 % ) of these had AF on st and ard ECG or HM . Of the remaining patients , 121 refused ICM implantation . In total , 105 patients ( median age 65.4 years [ range 27.1 - 80.8 ] , 46 % males ) received an ICM , which revealed AF in 7 ( 6.7 % ) . Factors associated with new-onset AF were a history of recurrent TIA ( odds ratio [ OR ] 11.5 , 95 % confidence interval [ CI ] 2.1 - 63.6 ) and heart failure ( OR 12.7 , 95 % CI 1.71 - 96.83 ) . CONCLUSIONS The 1-year incidence of AF in TIA patients with normal ECG and HM was 6.7 % using an ICM . Factors associated with development of AF were recurrent TIA and heart failure Background and Purpose — A new clinical construct termed embolic stroke of undetermined source ( ESUS ) was recently introduced , but no such population has been described yet . Our aim is to provide a detailed descriptive analysis of an ESUS population derived from a large prospect i ve ischemic stroke registry using the proposed diagnostic criteria . Methods — The criteria proposed by the Cryptogenic Stroke/ESUS International Working Group were applied to the Athens Stroke Registry to identify all ESUS patients . ESUS was defined as a radiologically confirmed nonlacunar brain infa rct in the absence of ( a ) extracranial or intracranial atherosclerosis causing ≥50 % luminal stenosis in arteries supplying the ischemic area , ( b ) major-risk cardioembolic source , and ( c ) any other specific cause of stroke . Results — Among 2735 patients admitted between 1992 and 2011 , 275 ( 10.0 % ) were classified as ESUS . In the majority of ESUS ( 74.2 % ) , symptoms were maximal at onset . ESUS were of moderate severity ( median National Institute Health Stroke Scale score , 5 ) . The most prevalent risk factor was arterial hypertension ( 64.7 % ) , and 50.9 % of patients were dyslipidemic . Among potential causes of the ESUS , covert atrial fibrillation ( AF ) was the most prevalent : in 30 ( 10.9 % ) patients , AF was diagnosed during hospitalization for stroke recurrence , whereas in 50 ( 18.2 % ) patients AF was detected after repeated ECG monitoring during follow-up . Also , covert AF was strongly suggested in 38 patients ( 13.8 % ) but never recorded . Conclusions — About 10 % of patients with first-ever ischemic stroke met criteria for ESUS ; covert paroxysmal AF seems to be a frequent cause of ESUS Aims Uncertainty exists over the importance of device-detected short- duration atrial arrhythmias . Continuous atrial diagnostics , through home monitoring ( HM ) technology ( BIOTRONIK , Berlin , Germany ) , provides a unique opportunity to assess frequency and quantity of atrial fibrillation ( AF ) episodes defined as atrial high-rate events ( AHRE ) . Methods and results Prospect i ve data from 560 heart failure ( HF ) patients ( age 67 ± 10 years , median ejection fraction 27 % ) patients with a cardiac resynchronization therapy ( CRT ) device capable of HM from two multi-centre studies were analysed . Atrial high-rate events burden was defined as the duration of mode switch in a 24-h period with atrial rates of > 180 beats for at least 1 % or total of 14 min per day . The primary endpoint was incidence of a thromboembolic ( TE ) event . Secondary endpoints were cardiovascular death , hospitalization because of AF , or worsening HF . Over a median 370-day follow-up AHRE occurred in 40 % of patients with 11 ( 2 % ) patients developing TE complications and mortality rate of 4.3 % ( 24 deaths , 16 with cardiovascular aetiology ) . Compared with patients without detected AHRE , patients with detected AHRE>3.8 h over a day were nine times more likely to develop TE complications ( P= 0.006 ) . The majority of patients ( 73 % ) did not show a temporal association with the detected atrial episode and their adverse event , with a mean interval of 46.7 ± 71.9 days ( range 0–194 ) before the TE complication . Conclusion In a high-risk cohort of HF patients , device-detected atrial arrhythmias are associated with an increased incidence of TE events . A cut-off point of 3.8 h over 24 h was associated with significant increase in the event rate . Routine assessment of AHRE should be considered with other data when assessing stroke risk and considering anti-coagulation initiation and should also prompt the optimization of cardioprotective HF therapy in CRT patients Atrial fibrillation ( AF ) is common during the course of acute myocardial infa rct ion and is associated with left atrial ( LA ) dilatation . However , the role of LA depolarization abnormality on the  electrocardiogram ( ECG ) in the setting of LA dilatation was not studied in this context . Patients admitted with non-ST-segment elevation myocardial infa rct ion ( NSTEMI ) who developed new-onset AF ( International Classification of Diseases , Ninth Revision code 427.31 ) were prospect ively identified . Baseline ECGs and echocardiograms before the admission event were review ed . Follow-up was directed toward pertinent cardiovascular events , atrial tachyarrhythmias , and death as end points . Of 101 patients with NSTEMI who had new-onset AF , 88 had current echocardiograms and 69 had LA dilatation ( 78 % ) . Total follow-up was 24 months ( mean 21.4 ) . Prolonged P-wave duration ( > or = 110 ms ) and decreased left ventricular fractional shortening were most significant in those with LA dilatation and were independently associated with AF . In those with LA dilatation , the prevalence of such abnormal atrial depolarization on ECGs was 56 % . AF ( 43 % vs 15 % ; p = 0.03 ) and heart failure ( 63 % vs 35 % ; p = 0.03 ) occurred more often in this subset , but there was no difference in mortality . However , the overall prevalence of late cardiovascular complications in this subset was higher ( 71 % vs 45 % ; p = 0.02 ) compared with that of immediate complications ( 20 % vs 26 % ; p = 0.60 ) . In conclusion , there is higher recurrence of AF in patients with NSTEMI who have a combination of electrocardiographic and echocardiographic LA abnormalities compared with those without
Longer duration of electrocardiographic monitoring after cryptogenic stroke is associated with a greater detection of AF .
BACKGROUND Atrial fibrillation ( AF ) is a major cause of stroke .
Although st and ard investigations after an event include electrocardiographic monitoring , the optimal duration to detect AF is unclear .
We performed a systematic review and meta- analysis to determine whether the duration of electrocardiographic monitoring after an ischemic event is related to the detection of AF .